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THE  LIBRARY 

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OF  CALIFORNIA 

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GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


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5Q72 

AN    INDEX 


OF 


S  IT  E  a  E  E  T 


BEING 


A    CONCISE    CLASSIFICATION    OF    THE    lilAIN    FACTS    AND 

THEOEIES  OF  SUKGERY,   FOR  THE  USE  OF  SENIOR 

STUDENTS  AND  OTHERS 


BY 

C.   B.   KEETLEY,   RRC.S., 

SENIOR  ASSISTANT  SCEGEON  TO  THK  WEST  LONDOK  HOSPITAL  ;   3CRGE0N  TO   THE  SUEGICAL   AID  SOCIETY 


NEW  YORK 
WILLIAM    WOOD    &    COMPANY 

1882 


Trow's 

Feinting  and  Bookbinding  Company 

201-213  East  Twelfth  Street 

New  York 


11  -  . 

wo 

lOO 


THE  COMMITTEE 
AND    TO    MY   COLLEAGUES    ON    THE    STAFF 

OF   THE 

WEST  LOFDON  HOSPITAL 
STIjis  little  Book  is  iDebicatelr 

AS  A  TOKEN  OF   RESPECT   AND  FEIENDSHIP 


G03.'tf>5 


PREFACE. 


This  book  is  intended  to  be  read  by  the  senior  student  shortly 
before  he  goes  in  for  his  fuial  examination,  and  after  he  has  carefully 
studied  a  complete  text-book  of  surgery.  When  I  was  about  to  pre- 
sent myself  at  the  iinal  examination  for  the  Fellowship  of  the  College 
of  Surgeons,  I  felt  the  need  of  some  such  work.  I  had  read  not  only 
more  than  one  manual,  but  several  special  treatises  and  various  essays. 
I  had  had  at  least  ordinary  opportunities  of  practical  work,  and  I  do 
not  think  I  had  wasted  them.  But  I  had  made  no  complete  series  of 
surgical  notes,  nor  could  I  possibly  have  made  such  a  series  without 
having  unduly  narrowed  my  reading  or  trespassed  on  the  time  spent  in 
the  hospital  wards.  And  this  very  narrowing,  still  more  this  very 
trespassing,  would  have  made  me  unqualified  to  make  a  good  note- 
book at  all.  For,  to  make  good  notes,  one  should  have  some  practi- 
cal experience  and  some  bi'eadth  of  view.  How  many  men  have  had 
to  put  aside  as  useless  the  notes  once  laboriously  made,  but  made  with 
unripe  knowledge,  and  with  the  bad  judgment  which  such  immaturity 
implies ! 

I  am  not  dissuading  students  from  taking  notes  while  reading. 
The  practice  is  highly  to  be  commended  for  various  reasons ;  for  in- 
stance, it  rivets  the  attention — an  essential  part  of  memory — and  it 
frequently  results  in  a  note-book  of  high  value,  well  worth  reperusal. 
But  the  more  honestly  that  note-book  is  made,  the  more  likely  will 
the  student  be  to  find  the  examination  drawing  swiftly  near  and  his 
reading  creeping  along  but  slowly.  He  feels  compelled  to  desert  his 
note-book,  and  frequently  his  text-book  too.  He  either  skims  on  to 
the  end  of  the  latter,  haste  and  anxiety  preventing  him  from  thought- 
fully studying  it,  or  he  leaves  it  altogether  for  the  smallest  "  Intro- 
duction" to  surgery  in  the  language.  Now  an  "Introduction"  or 
"  Elementary  Handbook  "  ha?  its  proper  place  in  education  ;  but  that 


VI  PREFACE. 

proper  place  is  not  the  time  just  before  a  final  examination,  especially 
when  it  comes  in  to  thrust  out  a  more  profound  and  elaborate  treatise. 

If  the  student  knew  that  there  was  a  short  book  accessible,  con- 
taining the  main  facts  and  theories  of  surgery  put  concisely,  classified 
and  arranged  in  due  order,  and  without  superfluous  explanation,  he 
would  be  able  to  really  study  his  familiar  text-book  up  to  the  last 
month  before  his  examination,  i-elying  upon  such  a  short  book  to  give 
form  to  any  knowledge  which  then  remained  nebulous  in  his  mind. 

These  considerations  convince  me  of  the  justness  of  the  purpose  of 
my  book.  Of  its  execution  I  will  say  nothing.  The  shortcomings  of 
a  book  which,  insignificant  as  it  is,  deals  with  questions  of  life  and 
death,  can  scarcely  be  excused ;  they  can  only  be  lamented  and  con- 
demned. But  as  I  am  convinced  that  it  will  do  much  more  good  than 
evil,  and  I  believe  I  have  done  my  best,  I  publish  the  work  hopefully. 
These  shortcomings  would  have  been  much  greater  if  it  had  not  been 
for  the  help  in  revision  which  has  been  given  by  Messrs.  Alfred 
Street,  Mills,  Dunn,  Alfred  Back,  Firth,  and  Charles  Paget.  Mr. 
Street  has  gone  over  the  whole  book.  I  cannot  thank  him  too 
warmly.  My  friend  and  pupil,  Mr.  Chai-les  H.  Taylor,  has  made  the 
Index  of  Il^ames. 

Messrs.  Dokan,  Lyons,  and  Juler  have  added  contributions  on 
Ovariotomy,  Toothache,  and  Ophthalmic  Surgery  respectively. 

Mr.  Juler  desires  acknowledgment  to  be  made  of  the  lielp  given  by 
Mr.  W.  Adams  Frost  and  Mr.  "W".  Langdon,  in  the  revision  of  the 
article  on  Ophthalmic  Surgery. 

Finally,  I  will  express  a  hope  that  the  practitioner,  as  well  as  the 
student,  will  occasionally,  find  the  book  useful  as  a  handy  little  work 
of  reference. 

30  Princes  Street,  Hanover  Square, 
London,  W.,  September,  1881. 


INDEX  OF  SURGERY. 


Abdomen,  Contusions  of. — Always  examine  patient  very  carefully, 
but  gently.  Diagnose  whether  the  viscera  are  injured  or  not.  Three 
things  protect  against  injury  to  the  deeper  stnictures,  viz. :  1,  thick  and 
muscular  abdominal  walls ;  2,  empty  state  of  the  viscera ;  and  3,  the 
patient's  foreseeing  and  expecting  the  blow. 

The  parietal  effects  of  a  blow  on  the  abdomen  are :  1,  rupture  of  mus- 
cle ;  2,  mere  bruising  (which,  however,  may  be  very  serious  in  extent)  ;  3, 
rupture  of  the  peritoneum,  with  consequent  extravasation  of  blood  into 
peritoneal  cavity.  Rupture  of  a  muscle  causes  temporary  paralysis,  swell- 
ing, etc.  Sometimes  the  separation  of  the  parts  may  be  felt.  Abscess  may 
follow  contusion,  burrow  widely,  and  cause  most  troublesome  sinuses. 
Hemon-hage  from  ruptured  peritoneum  may  be  fatal.  The  collapse  so 
produced  is  distinguished  fi'om  the  effect  of  ruptured  intestine  by  the 
absence  of  great  pain  and  vomiting,  and  by  positive  signs  of  internal 
hemorrhage. 

A  blow  on  the  abdomen  may  cause  serious  and  even  fatal  collapse 
without  visceral  injury,  possibly  by  damaging  the  abdominal  sympathetic 
system.  Tj-eatment. — Attend  to  collapse,  internal  hemorrhage,  inflamma- 
tion, and  suppuration  on  general  principles.  Avoid  purgatives.  In  case 
of  peritonitis,  use  leeches,  warm  moist  applications,  and  a  liberal  allowance 
of  opium.  Mercury  in  case  of  sthenic  inflammation.  When  there  is 
injury  to  a  visctts,  the  particular  one  injured  depends  chiefly  upon  the 
place  where  the  force  is  applied.  Each  viscus  presents  special  symptoms. 
Liver  and  stomach  most  commonly  suffer. 

Rupture  of  Liver. — Symptoms. — Pain  in  hepatic  region,  signs  of  internal 
hemorrhage,  peritonitis,  bilious  vomitings,  white  stools.  Traumatic  sac- 
charine diabetes  (Bernard). 

Rupture  of  Gall-Bladder. — Great  pain,  collapse,  and  anxiety.  Rapid 
death. 

Rupture  of  Stomach. — Bloody  vomiting,  local  pain,  and  general  signs 
of  abdominal  injury. 


Z  ABDOMEN,    WOUNDS    OF. 

RuPTTJKE  OP  Intestines. — Bloody  stools  and  general  signs  of  abdominal 
injury.     Most  frequently  affects  the  jejunum.     Emphysema. 

RuPTUKED  Spleen. — Sevei*e  internal  hemorrhage. 

Ruptured  KmNEY. — Pain  and  bruise  in  loins.  Blood,  and,  if  an  abscess 
should  form,  j)us  in  urine.  Vomiting,  retraction  of  testicle,  numbness  of 
thigh.     Less  hopeless  than  injury  of  the  other  viscera. 

Ruptured  Ureter  has  occurred,  causing  a  large  accumulation  of  urine 
on  the  same  side  of  the  abdomen  :  recovery. 

Ruptured  Bladder. —  Vide  Bladder,  Rupture  of. 

Treatment  of  Ruptured  Viscera. — Perfect  rest,  warm  and  moist  applica- 
tions to  seat  of  pain,  leeches  if  pain  be  severe,  opium  in  small  and  repeated 
doses,  a  minimum  diet — starvation  if  the  intestines  are  believed  to  be 
wounded — then  give  frequent  small  nutrient  enemata.  No  purgatives. 
Ice  to  suck. 

Abdomen,  Wounds  of. — Are  either  superficial  or  penetrating.  Pene- 
trating are  of  four  classes :  1,  without  either  injury  or  protrusion  of 
viscera ;  2,  with  protrusion  only  ;  3,  with  injury  and  without  protrusion  ; 
and  4,  with  both  injury  and  protrusion. 

Superficial  Wounds. — Their  Treatment. — Keep  sides  in  apposition  by 
sutures  and  a  suitable  position  of  the  body,  but  beware  of  confining  blood 
or  discharge.  1,  always  secure  the  bleeding-point  in  severe  hemorrhage, 
enlarging  wound  if  necessary  ;  2,  in  shghter  hemorrhage  do  not  close 
wound  till  bleeding  stops  ;  3,  open  wound  freely  at  least  sign  of  suj^pura- 
tion.  Part  of  abdominal  wall  which  is  wounded  is  liable  to  become  seat 
of  hernia.  Foreign  bodies  of  enormous  size  may  be  hidden  away  in  these 
wounds. 

Simple  Penetrating  Wounds. — Sometimes  marked  by  escape  of  reddish 
serum.  If  sutures  should  be  required,  jDlace  them  close  to  or  through 
peritoneum,  give  opium,  and  apply  general  principles  of  practice.  Prog- 
nosis faii'ly  good. 

Wounds  with  Protrusion  of  Uninjured  Viscera. — Cleanse  and  return 
protrusion  ;  if  necessarj',  snick  edge  of  wound  to  make  room.  Omentum, 
if  much  injured,  may  be  cut  off  after  hgaturing.  See  that  the  herni- 
ated viscera  are  fairly  and  entirely  passed  into  abdominal  cavity,  and  not 
slipped  between  muscles.  Gangrenous  bowel :  leave  it  in  situ  to  slough,, 
and  form  artificial  anus. 

Wounds  with  Injury  and  without  Protrusion. — Very  serious.  Possible 
escape  of  urine,  faeces,  bile,  or  gas  through  external  wound.  Extravasation 
into  peritoneal  cavity  not  invariable.  Other  symptoms  and  treatment  like 
those  of  contusion  of  abdomen  with  rupture  of  viscera.      Vide  above. 

Wounds  with  both  Injury  and  Protrusion. — Treatment. — Restrain  hemor- 
rhage by  ligature  or  clamp.  Do  not  be  anxious  to  return  solid  viscera  if 
they  are  at  all  seriously  injured.  Sew  up  wounds  of  intestine  with  silk  or 
strong  catgut.     Glover's  suture,  unless  the  wound  be  lacerated  or  involve 


ABSCESS.  6 

mucli  of  bowel's  calibre  ;  then  stitch  bowel  to  edge  of  external  wound  to 
form  artificial  anus.  Allow  no  food,  except  ice  and  barley-water,  for 
three  days.  See  also  Peritonitis  (Traumatic),  Fistula  (Gastric  and  Bil- 
iary), Artificial  Anus. 

Abscess. — A  circumscribed  collection  of  pus.  Two  chief  kinds,  acute 
and  chronic.  Term  "  cold  "  is  sometimes  used  as  synonymous  with  chronic, 
and  sometimes  means  a  chronic  abscess  which  has  formed  without  any 
noticeable  signs  of  inflammation. 

Acute  Abscess. — Causes. — Injury,  irritation  of  a  foreign  body,  follicular 
obstruction,  absorption  of  poison,  especially  by  lymphatics,  and  some 
obscure  constitutional  conditions.  Symptoms. — Chills,  rigors  ;  tempera- 
ture often  rises  suddenly  to  104°.  Local  symptoms  of  inflammation. 
Throbbing  pain,  which  becomes  more  dull  and  aching  as  pus  forms. 
(Edema  of  skin.  Fluctuation.  The  swelling,  which  is  at  first  hard, 
gradually  softens  in  centre.  Pointing  of  abscess :  the  cuticle  rises,  the 
skin  ulcerates  or  sloughs,  and  bursts.  Terminations. — 1,  when  opened 
either  surgically  or  spontaneously,  its  walls  fall  together  and  it  closes  ;  2, 
a  sinus  or  fistula  remains  ;  3,  acute  abscesses  sometimes  cause  serious  mis- 
chief by  opening  into  blood-vessels  and  serous  cavities.  Diagnosis. — An 
acute  abscess  can  scarcely  be  mistaken.  Treatment. — Local  rest  very  im- 
portant ;  general  rest  in  serious  cases.  Treat  cause  if  possible.  Warm 
moist  applications.  Quinine  internally.  Calomel  (5  to  10  grains)  if  the 
tongue  is  not  clean.  Indications  for  Opening. — 1,  when  in  sheath  of  a  ten- 
don ;  or  2,  under  strong  fibrous  membranes  ;  or,  3,  anywhere  else  where 
pus  is  likely  to  burrow  instead  of  coming  to  the  surface  ;  4,  near  a  joint ; 
5,  under  the  periosteum  ;  6,  when  pressure  is  likely  to  be  dangerous  ;  7, 
when  it  may  cause  some  direct  obstruction  to  some  passage  ;  8,  when 
caused  by  some  noxious  infiltrating  fluid,  e.g.,  urine  ;  9,  when  a  spon- 
taneous opening  would  produce  deformity,  e.g.,  in  neck  ;  10,  when  near 
anus.  After  abscess  is  open,  employ  pressure,  if  necessary,  to  prevent 
fistula ;  but  poulticing  usually  suffices  as  a  dressing.  Method  of  Opening 
Acute  Abscess. — 1,  By  Paget's  or  Syme's  knife  or  lancet ;  2,  by  Hilton's 
method  when  deep  and  in  a  dangerous  situation.  "Hilton's  3Iethod." — 
Incise  skin  and  deep  fascia,  then  push  a  director  on  into  abscess ;  lastly, 
pass  a  pair  of  dressing-forceps  along  director,  and  when  they  have  entered 
the  cavity,  open  the  blades.  Opening  to  be  dependent,  parallel  with  any 
neighboring  imj)ortant  structures,  and  free. 

Chronic  Abscess. — Causes. — Dead  bone  :  all  causes  of  acute  abscess, 
quod  vide.  Scrofula.  Constitutional  debility.  Signs. — A  swelhng,  at  first 
hard,  afterward  soft  and  fluctuating,  usually  situated  near  a  lymphatic 
gland,  or  in  some  special  situation,  e.g.,  in  the  psoas  muscle,  or  in  loose 
cellular  tissue,  e.g.,  that  of  buttock.  Often  a  certain  amount  of  pain  and 
tenderness  ;  often  evident  disease  of  bone.  Pressure  on  nerves  may  cause 
pain  or  spasm.     Abscesses  near  mucous  canals  sometimes,  but  rarely, 


4  ADENOCELE,    ADENOMA. 

become  emphysematous.  Course. — Often  very  tedious,  usually  tends  to 
burst,  either  through  skin  or  into  some  internal  cavity,  but  usually  the 
former.  May  remain  stationary  for  years  ;  and  may  contract  while  its  con- 
tents partly  degenerate,  partly  are  absorbed.  Constitutional  Effects. — 
Usually  little  or  none  till  it  opens  and  its  contents  are  exposed  to  the  air. 
Then,  if  the  abscess  be  of  any  size,  decomposition  of  its  contents  tends  to 
occur  with  high  fever.  Vide  Hectic  Fever,  Septiccemia,  etc.  Liability  to 
burrow,  to  open  into  important  vessels,  and  to  cause  injurious  pressure 
effects.  Diagnosis. — From,  1,  innocent  and  malignant  tumors  ;  2,  aneu- 
risms. 1,  in  cases  of  doubt,  use  trochar,  grooved  needle,  or  aspirator.  2, 
■mde  Aneueism.  Prognosis  depends  upon  size,  position,  age  of  patient, 
curability  of  cause,  and  upon  treatment.  Middle  age  most  hopeful. 
Treatment. — Remove  cause,  vide  Games.  If  there  is  no  great  tensive  pain, 
or  if  there  is  no  reason  to  suspect  that  burrowing  is  going  on,  opening 
may  be  delayed.  An  effort  may  be  made  to  obtain  resolution  by  counter- 
irritation,  iodine,  mercurial  plasters,  and  rest.  Various  modes  of  ojDen- 
ing  :  1,  by  knife  ;  2,  by  trochar  and  canvda  ;  3,  aspirator ;  4,  caustics. 
Free  openings,  counter-openings,  drainage-tubes,  repeated  partial  evacua- 
tions by  aspirators,  etc.  Antiseptic  treatment,  quod  vide.  Dangerous  septic 
symptoms,  a  probable  consequence  of  prematurely  opening  a  chronic 
abscess. 

Puerperal  Abscesses  occiu'  after  parturition  ;  are  probably  pysemic  in 
nature.     Locality. — Iliac  fossa,  orbit,  joints,  thigh,  etc. 

Acupressure. — Four  chief  modes :  1,  a  long  needle  is  thrust  right 
through  flap  and  made  to  bridge  over  artery ;  2,  a  short  needle,  with  a 
twisted  wire  through  eye  to  extract  it  by,  is  thrust  into  soft  tissues  on 
each  side  of  and  made  to  bridge  over  artery  ;  3,  the  vessel  is  compi-essed 
between  a  needle  and  a  loop  of  wire,  like  the  common  hare-lip  suture  ;  4, 
needle  is  thrust  through  soft  tissues  beside  artery,  then  twisted  down  upon 
the  artery  through  an  arc  of  a  circle,  and  thrust  into  the  neighboring  soft 
tissues  again.  Advantages  of  acupressure. — No  foreign  body  is  left  in 
wound  more  than  a  day  or  two,  as,  after  that  time,  the  needles  are  re- 
moved. A  few  hours  suffice  for  small  arteries.  Acupressure  does  capitally 
in  scalp-wounds  and  when  varicose  veins  bru-st.  Vide  Pin'ie's  and  Sir 
James  Simpson's  writings. 

Adenitis. —  Fide  Glands,  Diseases  of. 

Adenocele,  Adenoma. — Glandular  Tumor.  A  growth,  the  whole  or 
part  of  whose  structure  resembles  that  of  some  gland.  (But  the  term 
"  Lymphoma  "  is  usually  applied  to  any  tumor  resembhng  lymphatic  gland. ) 
When  not  pxire  these  tumors  ai'e  called  Adeno -sarcoma,  Adeno-myxoma, 
etc.  Occurrence. — In  the  "mucous  polypi"  of  the  nose,  rectum,  and 
uterus,  vide  Polypi ;  in  thyroid  gland,  vide  Bronchocele ;  in  parotid,  lips, 
tonsils,  and  skin.  Physical  Character. — Movable,  rounded,  ovoid,  or  lobu- 
lated.      Growth,   variable   in  rapidity.      Treatment. — Divide  capsule   and 


AMPUTATION.  0 

enucleate  in  suitable  cases.  Also  refer  to  articles  Polypi,  Bronchocele, 
Breast  Tumor,  etc. 

Amputation. — (When  through  a  joint,  it  is  termed  Disarticulation.) — 
When  required. — For  incurable  and  disabling  disease,  deformity,  or  injury 
of  the  part ;  for  disease  which  would  take  too  long  time  in  reeoveiy ;  to 
save  life  when  nature  would  find  it  easier  to  heal  the  amputation  wound 
than  to  ciu'e  the  disease  or  injury  ;  for  aneurism  below  or  even  above  the 
site  of  operation  ;  for  secondary  hemorrhage. 

General  Principles. — 1,  Remove  no  more  of  a  Umb  than  is  necessary ; 
2,  obtain  sufficient  coverings  for  the  stump  ;  3,  arrange  that  the  cicatrix 
shall  not  He  on  the  end  of  the  bone ;  4,  do  not  take  hopelessly  unsound 
tissue  into  the  flaps  ;  5,  take  every  precaution  to  check  hemorrhage  and  to 
prevent  its  reciu-rence  ;  6,  cut  the  large  blood-vessels  transversely ;  7, 
remember  the  paramount  importance  of  dressings  and  after-treatment. 

Instruments. — 1,  Knives  appropriate  to  each  case  ;  2,  saw ;  3,  bone- 
forceps  ;  4,  lion-forceps  ;  5,  common  scalpels  ;  6,  artery-forceps  ;  7,  dissect- 
ing-forceps ;  8,  ligatures ;  9,  needles  and  sutiires ;  10,  dressings,  sponges, 
retractors,  towels,  water,  etc. 

Assistants. — 1,  Chief,  who  sponges,  secures  arteries,  etc.,  usually  stands 
opposite  operator  ;  2,  holds  part  to  be  removed  ;  3,  secvires  main  artery, 
unless  tourniquet  be  used  ;  4,  hands  instruments  when  wanted  ;  5,  chlo- 
roformist.  Number  of  assistants  of  course  depends  greatly  on  supply 
accessible. 

Methods. — 1,  Circular ;  2,  oval ;  3,  flap  ;  4,  mixed  of  skin -flaps  and  cir- 
cular cut  through  muscles. 

Steps. — 1,  Divide  soft  parts  ;  2,  saw  bone  (avoid  splintering,  cut  off 
spiculse) ;  3,  tie  vessels  and  trim  soft  tissue  ;  4,  adjust  flaps  and  insert 
sutures  ;  5,  apply  first  dressings. 

Circular  Ajmputation. — 1,  Sweep  through  skin  and  fat  and  dissect  up 
for  half  diameter  of  limb,  turning  edge  of  knife  slightly  away  from  skin  to 
avoid  scoring  the  vessels  which  supply  the  skin-flap  ;  2,  sweep  through 
muscles,  "retracting"  all  the  time;  3,  still  having  the  muscles  well  re- 
tracted, one  or  two  inches,  and  having  divided  the  periosteum  by  a  sweep 
of  the  knife,  saw  through  bone.     Finish  as  directed  above. 

OvAii  Amputation. — See  amputation  of  finger  at  metacarpo-jDhalangeal 
joint. 

Flap  Amputatiox. — Three  varieties  :  1,  Double  Flap  ;  2,  Eectangular 
(Teale's)  ;  3,  One  Long  Flap. 

Double  Flap  may  be  lateral,  antero-posterior,  or  oblique.  Cut  thin 
flaps  from  without  inward,  but  thick  and  fleshy  ones  by  transfixion.  Flap 
containing  vessels  to  be  cut  last,  and  vessels  cut  long. 

Rectangular  Flaps  ( JfeaZe's).— All  the  soft  tissues  down  to  the  bone  in- 
cluded in  the  flaps.  Main  artery  to  be  in  short  flap.  Ends  of  flaps  square. 
Long  flap :  its  length  and  breadth  each  equal  half  the  circumference  of 


6  AMPUTATION. 

the  limb.  Short  flap  :  its  length  equals  one-fourth  that  of  long  flap. 
Bones  sawn  exactly  at  angle  of  union  of  flaps,  without  any  retraction. 

Spence's  Operation  (a  modification  of  Teale's). — No  posterior  flap ;  re- 
traction instead.     Anterior  flap  simply  hangs  down  over  bone. 

Lister  cuts  an  anterior  rounded  flap  two-thirds  diameter  of  hmb  in 
length ;  skin  and  enough  muscle  to  cover  bone.  Posterior  rounded  flap 
(one-third  limb's  diameter),  aU  skin.  Posterior  muscles  cut  as  short  as 
possible  (to  free  flaps  from  effects  of  their  contraction).  Retract  soft  parts 
for  two  inches,  and  saw  bone. 

Single  Flap  amputation. —  Vide  amputation  at  phalangeal  joints  of 
fingers. 

Skin-Flaps  and  Circular  Incision  through  Muscles. — Cut  two  skin-flaps 
by  dissecting  from  without  inward.    Then  finish  as  in  cii'cular  amputation. 

Hemorrhage  dimng  amputation  to  be  prevented  temporarily  by' digital 
pressure  on  main  artery,  by  tourniquet,  or  by  Esmarch's  bandage.'  After- 
ward, ligature  by  sUk,  hemp,  or  catgut — torsion  or  acupressure  is  to  be 
emi^loyed.  Sponging  with  cold  or  with  hot  water  to  stop  oozing.^  Actual 
cautery  to  check  obstinate  bleeding  fi'om  bone. 

Muscles  retract  greatly  in  traumatic  cases,  but  veiy  little  in  limbs 
affected  with  old  disease.  Knife  to  be  used  with  a  free  sawing  motion. 
Parts  to  be  relaxed  during  transfixion.  Commence  sawing  the  bone  by 
drawing  the  saw  back  to  make  a  groove. 

Mortality  after  Amputation. — 1,  Chief  causes :  1,  shock  ;  2,  secondary 
hemorrhage  ;  3,  pyjemia  (in  nearly  half  the  fatal  cases)  ;  4,  erysipelas  ;  5, 
phlebitis ;  6,  congestive  pneumonia.  Besides  which,  7,  hospital  gangrene, 
8,  sloughing  of  stump,  and,  9,  tetanus,  occasionally  carry  off  patient. 
Pyaemia  most  common  after  traumatic,  rare  after  chronic  disease  cases. 

Circumstances  affecting  Patient's  Chance  of  Recovery. — Two  classes  :  1, 
constitutional  conditions  ;  2,  circumstances  of  operation  itself.  Class  1 : 
age,  general  health,  and  hygienic  conditions.  Child's  twice  as  good  as  a 
young  man's,  three  times  as  good  as  an  old  man's.  Class  2  :  seat  of 
amputation,  structure  of  bone  sawn  through  ;  whether  amputation  is  for 
injury  or  disease  ;  nature  of  the  affection  ;  time  after  the  injury.  Diseased 
kidneys,  town  life,  amputation  high  up  a  limb,  amputation  for  injury,  or 
thi'ough  much  cancellous  tissue  of  bone — all  these  darken  the  prognosis. 
Nature  of  disease  :  after  chronic  disease,  prognosis  good  ;  malignant  or 
tuberculous  disease,  bad ;  acute  suppurative  disease  of  joints,  very  bad  ; 
amputation  of  expediency,  very  bad.  Time  after  injury :  primary  or 
secondary.  Primary  are  such  as  are  done  within  thirty  hours  of  the  in- 
jury.    Secondary  are  amputations  done  after  suppuration  has  occurred. 

*  For  a  resume  of  the  advantages  of  Esmarch's  bandage,  see  London  Medical 
Record,  1874,  p.  271. 

*  See  Practitioner,  February,  1879. 


AMPUTATION.  i 

Primary  always  more  dangerous  than  secondarj',  except  in  amputations  of 
the  upper  extremity  done  in  civil  j)ractice.  Death  after  primary  amputa- 
tion usually  caused  by  shock,  hemorrhage,  or  exhaustion  ;  after  secondaiy, 
by  erysipelas,  pysemia,  etc. 

Amputation  at  Ajskle. — Pirogoff's. — Resembles  Syme's.  But  the  lower 
incision  extends  from  one  malleolus  to  the  other  across  the  sole  of  the  foot, 
and  inclines  forward  and  downward  ;  while  the  os  calcis  is  sawn  through 
obliquely,  downward  and  forwai'd,  just  behind  the  articular  surfaces  for 
the  astragalus.  The  posterior  piece  of  the  os  calcis  is  then  placed  in  ap- 
position with  the  tibia,  whose  articular  surface  is  previously  shced  off. 
The  resulting  stump  is  longer  than  Syme's ;  but  if  the  tarsus  is  diseased 
there  is  a  liability  to  return  of  the  disease  in  the  os  calcis. 

Syme's  Amputation. — Inner  angle  of  incisions  is  three-quarters  of  an 
inch  below  and  behind  inner  malleolus  ;  outer  angle  exactly  opposite  outer 
malleolus.  Upper  incision  has  an  angle  of  45°  to  sole  of  foot ;  lower  in- 
cision inclines  downward  and  somewhat  backward.  Os  calcis  may  ^e  dis- 
sected from  heel-flap  either  before  or  after  disarticulation  at  ankle,  i.e., 
either  from  below  or  from  above.  Syme  dissected  out  os  calcis  from  be- 
low, and  disarticulated  afterward.  Avoid  scoring  flap.  The  anterior  tibial 
and  both  plantar  arteries,  and  not  the  posterior  tibial,  are  divided. 

Arm,  Amputation  of. —  Upper  Arm. — Double  flap  by  transfixion  often 
employed.  Also  circular  and  mixed  operation.  Arteries  divided  ;  brachial, 
superior  profunda,  and  inferior  profunda. 

Forearm. — In  upper  and  lower  thirds  prefer  skin-flap  and  circular 
through  muscles  (T.  Smith).  Arm  to  be  held  either  supine,  or  midway 
between  supination  and  pronation.  Arteries. — Eadial,  ulnar,  anterior  and 
posterior  interosseous. 

Elbow-Joint,  Disarticulation  at. — Seldom  done.  Best  to  cut  a  large  an- 
terior flap  (Lister). 

Fingers,  Amputation  of. — Usually  done  by  disarticulation.  To  remove 
the  second  or  third  phalanx,  cut  a  single  palmar  or  double  (palmar  and 
dorsal)  flaps.  As  the  heads  of  the  bones  form  the  knuckles,  the  articula- 
tions are  just  in  front  of  the  knuckles.  In  case  of  injiu'y,  here  as  else- 
where, "  cut  according  to  your  cloth." 

Metacarpo-phalangeal  Disarticulation. — So  called  "oval,"  really  "pyri- 
forin  "  incision.  Commence  half  an  inch  posterior  to  head  of  metacarpo- 
phalangeal joint,  carry  incision  right  round  palmar  surface  of  base  of  finger 
and  back  again.  Divide  lateral  ligaments,  twist  the  bone  out  of  its  place 
and  remove  it.  Extensor  tendon  should  be  cut  by  first  incision.  Removal 
of  head  of  metacarpal  makes  hand  more  sightly,  but  much  weaker. 

Foot,  Amputation  through. — Chopart's. — Between  scaphoid  and  cuboid 
on  the  one  hand,  and  astragalus  and  calcis  on  the  other.  Long  plantar 
flap,  reaching  to  roots  of  toes  ;  very  short  dorsal  flap.  Incisions  commence, 
on  inner  side,  just  behind  prominence  of  scaphoid  ;  on  outer  side,  one  inch 


b  AMPUTATION. 

behind  base  of  fifth  metatarsal  bone.  Beware  of  opening  ankle-joint.  Dis- 
articulate before  cutting  plantar  flap.  Plantar  flap  to  be  longer  on  inner 
than  outer  side.     Arteries. — Dorsalis  pedis,  plantar,  and  digitaL 

De  Ldgnerolles' .  — Removes  aU  the  bones  of  the  tarsus,  except  the  as- 
tragalus.    Heel  and  dorsal  flaps. ' 

Hancock's. — ^Leaves  the  astragalus  and  posterior  end  of  os  calcis,  on  the 
principle  of  Pirogofifs. 

Lisfranc's  (commonly  called  Hey's).^ — Between  tarsus  and  metatarsus. 
Long  plantar  flap,  reaching  to  roots  of  toes,  longer  on  inner  than  on  outer 
side.  Dorsal  incision  nearly  transverse,  with  only  sHght  convexity  forward. 
Ends  of  incisions,  on  inner  side,  one  inch  before  tubercle  of  scaphoid  ;  on 
outer  side,  just  behind  base  of  fifth  metatarsal.  In  disarticulating,  remem- 
ber dovetailing  of  second  metatarsal  bone  into  cuneiform  bones,  and  the 
obhquity  of  cuboido-metatarsal  joint.  Cut  plantar  flap  from  behind  for- 
ward after  disarticulation,  but  cut  its  borders  deeply  down  to  bone  when 
comrc^ncing  operation.     Arteries. — Dorsalis  pedis,  plantar,  and  digital. 

Hand,  Amputation  TmiouGH. — Not  a  single  bone  shotild  be  unnecessarily 
removed.  The  flaps  have  usually  to  be  taken  from  where  soft  tissues  are 
most  available. 

Hip-Joint,  Amputation  at. — Three  ways  :  1,  long  anterior  flap  ;  2,  dou- 
ble flap,  anterior  and  posterior ;  3,  lateral  flaps.  Use  Lister's  tourniquet 
for  aorta,  or  Davy's  lever  per  rectum  ;  let  patient's  buttocks  project  be- 
yond edge  of  table,  tie  body  and  sound  limb  to  table,  have  three  assistants, 
and  stand  on  left  side  of  limb.  Assistants :  1,  takes  charge  of  flap  and 
pays  greatest  attention  to  instantly  stopping  all  hemorrhage  ;  2,  manipu- 
lates hmb  :  he  has  mainly  to  prevent  locking  of  operating-knife,  especially 
by  keeping  great  trochanter  out  of  the  way  ;  3,  controls  tourniquet. 

Long  Anterior  Flap  Operation. — Left  hip :  transfix  from  a  point  midway 
between  ant.  sup.  spine  of  ilium  and  great  trochanter  to  another  point 
just  in  front  of  tuberosity  of  ischium.  Knife  should  pass  behind  femoral 
vessels  and  lay  open  hip-joint.  Right  hip  :  transfix  in  the  same  way,  but 
in  the  opposite  direction.  Other  operative  procedures  same  for  both  right 
and  left  limb.  Length  of  flap,  eight  or  ten  inches.  Next,  draw  knife 
across  capsule  of  joint,  opening  it  freely.  Divide  ligamentum  teres  and 
external  rotators.     Cut  vertically  do^vnward  through  remaining  soft  parts. 

Manipulations  bi/  Assistant  having  Charge  of  Ldmh. — 1,  while  anterior  flap 
is  being  formed,  flex  slightly,  adduct,  and  rotate  inward.  Then  extend 
and  rotate  outward,  till,  the  ligaments  being  divided,  head  of  femur  leaves 
its  socket  with  a  sucking  noise.  Then,  again  slightly  flex,  adduct,  and  ex- 
tend forcibly.  Absence  of  posterior  flap  favors  drainage.  Arteries. — Fe- 
moral, profunda,  obturator,  sciatic  and  minor  branches. 

'  Highly  praised  by  Nelaton. 

'  Hey's  operation  differs  from  Lisfranc's  in  that  the  former  saws  through  the 
second  metatarsal  bone. 


AMPUTATION.  9 

Douhle-jiap  Amputation. — Manipulations  and  proceedings  resemble  pre- 
ceding ;  but  there  are  two  flaps :  anterior,  five  inches ;  posterior,  four 
inches  long.  In  cutting  posterior  flap,  have  limb  rotated  inward  to  cleai* 
gi'eat  trochanter. 

Lateral  Flaps. — External  is  composed  of  skin.  Internal,  of  skin  and 
muscle,  is  cut  from  within  outward.  Angles,  where  flaps  join,  are  :  in 
front,  just  outside  femoral  vessels  ;  behind,  close  to  tuberosity  of  ischium. 

When  done  for  injury,  amputation  at  hip-joint  is  almost  always  fatal ; 
when  for  disease  ;  three  recover  out  of  five. 

Knee-Joint,  Disakticulation  at. — Chief  methods  :  1,  anterior  skin-flap ; 
2,  antero-posterior  double  flaps,  either  the  anterior  or  the  posterior  being 
the  longer  ;  3,  long  posterior  flap  (usually  including  flesh);  4,  lateral  skin- 
flaps  ;  5,  anterior  and  posterior  skin-flaps,  with  circular  incision  through 
muscles.  The  patella  is  generally  left ;  then  the  tendon  of  the  quadriceps 
extensor  may  be  divided.  Incisions  in  lateral  flap  method  begin  one  inch 
below  tubercle  of  tibia.  Flaps  to  be  somewhat  square.  Cai-tilage  to  be 
left,  unless  diseased.     Moi^tality. — For  disease,  one  in  three. 

Leg,  Amputation  of. — Any  one  of  the  ordinary  methods  can  be  used  ; 
but  double  skin-flaps  and  circular  through  muscles  are  very  good.  Care 
should  be  taken  not  to  lock  the  knife  between  the  two  bones,  and  not 
tujL'n  its  edge  upward  in  cleaning  between  the  bones.  The  sharp  anterior 
edge  of  the  tibia  should  be  bevelled  off  with  the  saw.  Sawing  through 
the  fibula  should  always  be  completed  before  the  division  of  the  tibia. 
Mortality. — For  disease,  one  in  twelve  ;  for  injvuy,  60  per  cent.' 

Penis,  Amputation  of. — Clover's  clamp  or  tape  to  check  hemorrhage. 
Corpus  spongiosum  to  be  cut  half  an  inch  longer  than  C.  cavernosa.  Value 
of  galvanic  cautery  ecraseur.  Urethra  to  be  spHt  into  three  and  sewn  to 
skin.  Skin  to  be  divided  higher  up  than  the  "  corpora,"  i.e.,  the  very  re- 
verse of  the  principle  adopted  in  amputating  a  limb. 

Shoulder-Joint,  Amputation  of. — Three  chief  methods,  viz.:  1,  lateral 
flaps  ;  2,  anterior  and  posterior  flaps  ;  3,  oval  incision.  But,  in  cases  of 
extensive  injury  to  upper  arm,  almost  any  operation  niay  be  expected  to 
give  a  satisfactory  stump. 

Lateral  Flaps. — Transfix  in  cases  of  injury.  Cut  from  without  inward 
when  for  disease.  Knife,  narrow-bladed.  Three  assistants  :  1,  holds  the 
limb  ;  2,  raises  the  flap  ;  3,  follows  the  knife  as  it  cuts  behind  the  hu- 
merus, and  grasps  the  inner  flap  with  the  axillary  artery.  Subclavian  may 
be  compressed.  Position  of  operator  :  for  right  limb,  stand  before ;  for  left 
limb,  stand  behind.  Right  side  :  enter  knife  midway  between  acromion 
and  coracoid  process.     Left  side,  enter  well  behind  spine  of  scapula,  at 


'  These  statistics  of  amputations  are  average,  and,  of  course,  differ  from  those  of 
some  exceptionally  successful  surgeons.  Moreover,  surgical  operations  have  been 
steadily  increasing  in  safety  for  years,  thanks  to  Lister  and  others. 


10  AMPUTATION. 

posterior  border  of  axilla.  Outer  flap  should  contain  most  of  deltoid. 
Secondly,  open  capsule,  divide  muscles  attached  to  great  tuberosity  (arm 
rotated  inward)  and  subscapularis  (arm  rotated  outward).  Thirdly,  having 
dislocated  head  of  humerus,  pass  knife  behind  it  and-  cut  down  for  a  dis- 
tance of  three  inches,  keeping  close  to  inner  side  of  bone  (so  as  not  to 
divide  artery  too  soon).  Then  complete  inner  flap  by  turning  edge  of 
knife  inward  and  cutting  through.  Arteries. — Axillaiy,  circumflex,  sub- 
scapular, etc. 

Oval  Amputation. — When  uncertain  whether  to  resect  joint  or  ampu- 
tate, perpendicular  incision  may  be  made  as  for  resection  {quod  vide),  and 
the  joint  examined.  Then,  if  desirable,  the  limb  can  after  all  be  removed 
by  cutting  obliquely  right  around  the  Hmb  from  and  to  the  lower  end  of 
the  longitudinal  incision.     This  is  Spence's  plan. 

Mortality. — For  disease,  one  in  two  ;  for  accident,  one  in  three. 

Thigh,  Amputation  of. — Methods. — 1,  Gritti's  ;  2,  Garden's  ;  3,  Spence's; 
4,  lateral  flaps  (Vermale's) ;  5,  circular ;  6,  double  flap  by  transfixion ;  7, 
mixed  ;  8,  Teale's. 

Gritti's. — Done  "just  above  condyles  with  an  anterior  flap,  in  which  the 
patella  is  preserved,  its  surface  being  sawn  and  applied  to  the  cut  surface 
of  the  femur."  Incision  extends  from  upper  end  of  fibula  to  inner  side  of 
joint,  reaching  downward  below  patella. 

Garden's. — Through  the  condyles.  Single  anterior  flap.  Circular  cut 
through  deeper  parts.  SHght  retraction  of  them  before  sawing  bone. 
Advantages. — The  medullaiy  canal  not  being  opened,  there  is  less  risk  of 
pyaemia.  The  skin  of  knee  is  accustomed  to  bear  weight  of  body  in  kneel- 
ing, etc.     Arteries. — Popliteal  and  some  of  its  branches. 

Spence's. — Long  anterior  ;  no  posterior  flap  ;  cu'cular  cut  through  mus- 
cles ;  retract  two  inches  and  saw  bone. 

Lateral  Flaps. — Not  to  be  recommended.  This  operation  and  the  other 
modes  of  amputating  thigh  all  done  in  the  ordinary  way.  Arteries. — Fem- 
oral, profunda,  external  circumflex,  anastomotica  magna  if  flap  reaches  low 
down,  muscular  branches. 

Mortality  of  Amputation  of  Thigh. — After  injury,  three  in  five  (much 
more  in  military-  practice) ;  after  disease,  one  in  three.  But,  for  chi'onic 
knee-joint  disease,  it  is  particularly  safe. 

Thumb,  Amputation  of. — 1,  At  Carpo-metacarpal  Joint. — Incision  along 
dorsum  of  metacarpal  bone,  commencing  at  palmar  side  of  trapezdo- 
metacai-pal  joint,  and  ending  at  web  of  thumb.  Flap  from  ball  of  thumb, 
by  transfixion.  Eight  thumb  :  transfix  first.  Left  thumb  :  transfix  after 
making  dorsal  incision.  Operator  should  stand  beside  the  hand  or  fore- 
arm, not  in  front  of  it ;  otherwise  his  own  left  hand  will  get  in  his  way. 
Beware  of  locking  knife  under  sesamoid  bones  ;  and  keep  close  to  meta- 
carpal bone,  to  avoid  wounding  radial  artery.  Arteries. — Dorsales  and 
arteria  magna  poUicis. 


ANESTHESIA.  11 

2,  Thumb  at  Metacarpo-phalaiigeal  Joint.  — 0\al  amputation. 

Toe,  Great. — At  Tarso-metatarsal  Joint. — Two  methods,  flap  and  oval. 

1.  Flap. — Cut  a  flap  from  whole  length  of  inner  side  of  metacarpal 
bone.  Better  not  transfix  for  this.  Then  transfix  between  first  and  second 
metacarpals,  and  cut  downward  right  through  web  of  toes.  If  possible, 
save  base  of  metacarpal  bone  ;  otherwise  divide  tendon  of  peroneus  longus 
aud  disarticulate.  Bewai'e  of  sesamoid  bones,  and  of  dividing  commu- 
nicating branch  between  dorsalis  pedis  and  external  plantar  artery  at 
base  of  interosseous  space.    Artery  divided  always. — First  digital. 

2.  Oval  Amputation. — Commence  incision  half-an-inch  posterior  to 
where  the  bone  is  to  be  divided  or  disarticulated. 

Toes. — Amputated  in  same  way  as  fingers. 

Anaesthesia. — The  term  usually  apphed  to  the  production  of  insensi- 
bility to  pain  for  surgical  or  medical  reasons.  This  state  is  induced  for 
five  pui-poses :  1,  to  reUeve  the  pain  of  operations  or  examinations  ;  2,  to 
facilitate  such  proceedings  as  the  reduction  of  dislocations  and  hernias  ;  3, 
where  spasm  interferes  with  diagnosis ;  4,  where  hysteria  or  malingering 
is  suspected  ;  5,  as  a  curative  agent,  e.g.,  in  puerperal  convulsions. 

Anaesthetics  are  either  general  or  local.  General  anaesthetics  in  ordinary 
use  :  1,  chloroform  ;  2,  ether ;  3,  a  mixttu-e  of  chloroform,  ether,  and 
alcohol ;  4,  bichloride  of  methylene  ;  5,  nitrous  oxide  gas. 

Their  physiological  action  consists  in  paralyzing  temporarily  almost  all 
the  nerve-centi'es,  except  those  necessary  to  maintaia  life. 

Advantages  and  Disadvantages  peculiar  to  Each. — Nitrous  oxide  is  the 
least  dangerous,  but  it  is  inconvenient  for  long  operations.  It  is,  par  ex- 
cellence, the  anaesthetic  for  short  operations.  Bichloride  of  methylene  has 
a  quick  action  and  causes  httle  vomiting.  Recovery  is  rapid  ;  but  it  is 
more  dangerous  than  ether,  and  perhaps  as  dangerous  as  chloroform.  It 
is  used  in  ophthalmic  surgerj'  and  for  ovariotomy.  Chloroform  has  a 
quick  and  powerful  action,  is  comparatively  agreeable  to  take,  and  seems 
safe  enough  for  children  ;  but,  for  adults,  is  more  dangerous  than  ether.  It 
frequently  causes  vomiting.  Ether  is  safe  and  powerful,  and  not  much 
slower  than  chloroform  when  properly  given.  On  the  other  hand,  the 
patients  sometimes  require  strong  assistants  to  manage  them  in  the  stage 
of  excitement ;  and  in  old  bronchitics  bronchial  irritation  is  produced.  As 
air  should  not  be  mixed  with  ether,  it  is  not  adapted  for  operations  about 
the  mouth.  The  mixture  of  alcohol,  chloroform,  and  ether  is  much  liked 
at  Guy's  Hospital.  (Chloroform  has  been  said  to  be  quite  safe  for  par- 
turient women,  but  several  deaths  have  been  recorded.) 

Ifodes  of  Administration. — Always  see  that  all  buttons  and  braces  about 
neck  and  chest  are  loose.  In  bloody  operations  about  the  mouth  the 
patient  should  sometimes  be  turned  on  his  side.  Prone  position  permis- 
sible if  required.  Carefully  watch  respirations  and  pulse,  especially  the 
former. 


12  ANESTHESIA. 

1.  Chloroform. — Eecumbent  position.  Clover's  inhaler.  Other  inhal- 
ers. Piece  of  lint.  Towel.  Allow  free  access  of  air.  Commence  gently. 
PoTor  3  ss.  upon  the  towel  to  begin  with. 

2.  Ether. — Best  administered  in  a  towel  folded  conically  with  a  sponge 
at  the  bottom,  or  in  a  cone  of  mackintosh  lined  with  felt.  Two  ounces 
are  not  too  much  to  begin  with,  and  the  drug  should  be  administered 
boldly,  especially  in  the  stage  of  excitement.  If  the  drug  be  pushed 
vigorously  then,  complete  anaesthesia  usually  follows  immediately  ;  if  in- 
decision or  timidity  be  displayed,  the  patient's  struggles  last  a  long  time. 
No  air  shovdd  be  allowed  to  get  under  the  apparatus,  which  should  be 
held  firmly  down  over  mouth  and  nose.  Patient  may  pull  it  off,  unless 
assistants  are  arranged  before  commencing  so  that  they  may  be  ready  to 
restrain  the  patient  the  moment  restraint  is  necessary.  §  j-  of  ether  is  to 
be  put  into  the  cone  from  time  to  time.  The  patient's  face  is  red  and  con- 
gested, and  his  breathing  ajit  to  be  stertorous.     Much  saliva  is  secreted. 

2a. — It  is  an  excellent  plan  to  administer,  successively,  nitrous  oxide 
and  ether,  a  mixtiu-e  of  the  two,  and  lastly  ether  alone.  Mr.  Clover  has 
contrived  an  apparatus  which  answers  this  purpose  admirably.  No  stimu- 
lant should  be  given  before  administering  ether.  Pure  anhydrous,  washed 
ether  always  to  be  used.    Robbins'  ether  for  local  anaesthesia  is  dangerous. 

3.  The  Mixture,  of  alcohol  1  part,  chloroform  2  parts,  and  ether  3 
parts,  is  to  be  given  like  chloroform  ;  but  the  air  should  not  be  allowed  to 
mix  quite  so  freely  with  the  vapor  (?). 

4.  Bichloride  of  Methylene. —  3  j-  is  placed  in  Rendle's  apparatus.  This 
is  a  cone  of  leather  lined  with  flannel,  has  smaU  perforations  at  the  apex, 
and  is  held  close  over  the  mouth  and  nose,  as  in  giving  ether.  If  a  second 
drachm  is  afterward  used  to  prolong  the  anaesthesia,  the  effects  resemble 
those  of  chloroform. 

5.  Nitrous  Oxide  Gas. — Is  given  perfectly  pure,  from  a  bag,  which  is 
replenished  from  an  iron  bottle,  which  contains  the  gas  compressed  to  a 
liquid  state.  The  appearances  produced  are  somewhat  alarming,  for  the 
blood  is  temporai'ily  "  un oxygenated,"  like  venous  blood.  But  this  is  not 
really  dangerous. 

Causes  of  Danger  from  AncBSthetics. — 1,  sudden  stoppage  of  respiration, 
either  from  paralysis  of  nerve-centre,  or  from  mechanical  obstruction,  e.g., 
falling  back  of  the  tongue,  or  passage  of  blood  into  larynx ;  2,  sudden 
paralysis  of  the  heart.  But  it  would  appear  that  heart  disease  does  not 
contra-indicate  anaesthetics  ;  and  ether  is  a  powerful  cardiac  stimiilant ;  3, 
shock. 

Precautions. — 1,  Do  not  push  the  anaesthetic  too  much  at  first.  Be 
careful  about  the  quantities  used  ;  2,  allow  plenty  of  air  with  chloroform  ; 
3,  recumbent  position,  especially  with  chloroform,  though  not  required 
with  gas  ;  4,  loosen  all  tight  coverings  on  chest  and  neck  ;  5,  have  ether  of 
the  right  quality  ;  6,  it  should  be  possible  to  let  a  free  supply  of  fresh  air 


ANEUEISM.  13 

into  the  room  if  necessary  ;  7,  administrator  should  confine  his  attention 
to  the  administration  only ;  8,  he  should  carefully  watch  the  pulse  and 
respiration — the  former  most  closely  with  chloroform,  and  the  latter  with 
ether. 

Treatment  of  Dangerous  Symptoms. — Pull  the  tongue  out  of  the  mouth. 
Clear  the  throat  out  if  there  be  any  suspicion  that  blood  or  vomited  food 
is  obstructing  the  larynx.  This  failing,  tracheotomy  may  be  found  justifi- 
able. Artificial  respu'ation.  Galvanism  :  one  pole  on  the  throat  near  the 
phrenic  nerve  ;  the  other  in  pit  of  stomach.  Hot  aflfusion  to  head.  Per- 
pendicular position,  with  head  downward.     As  much  fresh  air  as  possible. 

Local  Anesthetics. — Extreme  cold  produced  :  1,  ice  and  salt ;  or,  2, 
ether-spray.  Use  twice  as  much  powdered  ice  as  salt,  in  a  gauze  bag. 
Useful  for  small  operations  on  the  skin  or  about  the  nails,  excision  of 
small  ej)itheliomata,  etc. 

Aneurism. — A  considerable  dilatation  of  an  artery,  or  any  hollow 
tumor  communicating  with  the  interior  of  an  artery. 

Classification. — According  to  the  relation  of  its  sac  to  the  wall  of  the 
artery,  into  :  1,  true  ;  2,  false  ;  and  3,  dissecting  aneurism.  According 
to  its  shape,  into  fusiform  and  sacculated.  And,  according  to  its  apparent 
cause,  into  spontaneous  and  traumatic.  Cirsoid  aneurism  and  varicose 
aneurism  not  usually  included  in  this  classification. 

A  true  aneurism  used  to  always  mean  one  whose  sac  consisted  of  all 
three  arterial  coats.  The  term,  rarely  now  used  at  all,  often  means  merely 
that  the  sac  is  formed  chiefly  by  the  wall  of  the  arteiy.  False,  in  the  same 
way,  may  mean  either  that  the  sac  is  wholly,  or  that  it  is  chiefly,  formed 
of  tissues  outside  the  artery.  Dissecting  aneurisms  are  formed  when  the 
blood  burrows  between  the  coats  of  an  artery.  , 

Causes. — Dilated  arteries  are  almost  always  found  to  be  atheromatous 
(vide  Atheroma  of  Arteries) — 1,  occupation :  soldiers,  sailors,  employ- 
ments where  severe  and  prolonged  efforts  are  required  ii-regularly. 
Soldiers  are  chiefly  liable  to  thoracic,  sailors  to  subclavian  and  axiUary 
aneiu'isms  (probably  fi'om  climbing,  etc.)  ;  2,  abuse  of  alcohol  ;  3  syphilis: 
the  liabihty  of  soldiers  is  partly  attributed  to  the  latter  two  causes,  and 
partly  to  the  strain  on  the  thoracic  organs,  caused  by  the  old-fashioned 
stock  and  knaj)sack  ;  4,  strains  ;  5,  age  :  very  rare  in  childhood,  common- 
est between  thirty  and  forty  ;  6,  traumatic  aneurisms  are  caused  by  direct 
wounds. 

Pathology. — An  idiopathic  aneurism  begins  by  the  dilatation  of  a  dis- 
eased part  of  the  wall  of  some  artery.  The  whole  wall  may  be  so  softened 
as  to  dilate  ;  but  usually  the  inner  coat  is  ulcerated,  and  then,  from  the 
first,  the  aneurismal  sac  consists  only  of  the  outer  and  part  of  the  middle 
arterial  coat.  But  always,  before  the  tumor  reaches  the  size  of  an  average 
orange,  all  trace  of  distinction  between  the  arterial  walls  and  the  sur- 
rounding tissues  is  lost  in  its  sac.     In  the  meantime,  wherever  the  inner 


14  ANEURISM. 

coat  of  the  artery  is  absent,  the  blood  tends  to  deposit  layer  after  layer  of 
fibrin  :  the  outer  layers,  after  a  time,  have  become  organized  and  pale,  while 
the  inner  are  still  soft  and  dark-colored.  Fusiform  aneurisms  have  the 
inner  coat  of  the  artery  most  sound,  and  only  a  few  shreds  of  fibrin  ad- 
here to  their  walls.  The  waU  of  an  aneurism  itself  tends  to  thicken  and 
strengthen.  Adjacent  parts  are  pressed  upon,  nerves  are  irritated  or  par- 
alyzed, ducts  obstructed,  bones  absorbed. 

Symptoms. — Patient  generally  applies  for  advice  either  because  of  the 
swelling,  or  of  the  pain  caused  by  the  pressui'e  of  the  tumor ;  but  the 
earliest  symptoms  are  generally  those  of  slight  muscular  weakness  of  the 
limb.  Tumor,  in  the  course  of  some  artery,  soft  at  first,  harder  as  it  pro- 
gresses. Pulsation,  expansive.  Bruit,  loud  and  rasping,  or  soft,  or  alto- 
gether absent.  Pulse  below  aneurism  weak.  Often  oedema,  neuralgia, 
spasm  or  paralysis  from  pressxrre  on  veins  or  nerves.  ComjDress  artery 
above,  tumor  less  tense  or  smaller  ;  compress  artery  below,  tumor  may 
become  hu'ger  or  more  tense.  The  tumor  can  often  be  partially  emptied 
by  pressure. 

Diagnosis. — May  be  confounded  with  tumors,  or  abscesses  in  the 
course  of  large  arteries  ;  mahgnant  tumors  of  bone  ;  or  mere  enlargement 
and  relaxation  of  the  artery.  It  is  always  to  be  borne  in  mind  that  the 
pulsation  of  an  aneurism  is  heaving,  while  that  of  a  vascular  tumor  is  usu- 
ally sudden  and  more  abrujit  ;  also,  that  aneurisms  do  not  always  pulsate,' 
and  that  when  an  aneurism  is  emptied  by  pressure,  it  gradually  returns  to 
its  full  size.  Diagnosis  from  Tumors  and  Abscesses  pressing  on  the  Artery. — 
1,  such  swellings  mostly  have  no  bruit ;  2,  their  pulsation  is  an  equable 
rise  and  fall,  and  not  expansive  ;  3,  an  abscess  probably  shows  signs  of 
suppuration  (but  an  aneurism  may  suppurate  too)  ;  4,  the  tumor  can  often 
be  dragged  off  the  artery  which  commvmicates  to  it  its  pulsation. 

Diagnosis  from  Pulsatile  Tumors  of  Bone. — 1,  Bruit  in  pulsatile  tumor 
rarely  so  well  marked,  and  often  absent ;  2,  pulsation  more  sudden  and 
less  expansive  ;  3,  signs  are  often  to  be  found  in  the  state  of  the  neighbor- 
ing bone  :  thus,  a  plate  of  bone  may  be  felt  in  the  tumor.  Pulsatile  tu- 
mors may  dilate  the  bone  :  aneirrisms  cut  a  clean  hole  through  bone  ;  4, 
these  tumors  being  almost  always  cancerous,  may  be  accompanied  by  other 
signs  of  cancer.  Diagnosis  from  Aneurismal  Dilatation. — By  the  absence  of 
aU  marked  symptoms  of  a  genuine  aneurism.  ^ 

Prognosis. — Spontaneous  cure  does  sometimes  occur,  but  very  rarely. 
Without  treatment  a  fatal  event  from  bursting  of  the  sac  is  to  be  expected. 
With  treatment  the  patient's  chance  depends  mainly  on  the  situation  of 


'  For  diagnoses,  etc.,  of  aneurisms  which  do  not  pulsate,  see  Holmes,  in  British 
Medical  Journal,  Jan.,  1880,  and  Morrant  Baker,  in  St.  Bartholomew's  Hospital  Re- 
ports. 1879.     Auscultate  and  observe  the  effect  of  pressure  on  the  main  artery. 

"^  From  Holmes's  System,  vol  iii. ,  p.  455. 


ANEURISM.  15 

the  aneurism,  partly  on  its  cause,  tlie  fitness  of  the  case  for  operation,  and 
on  whether  the  anetirism  be  single  or  multiple. 

Course. — Enlargement  in  size  ;  formation  of  layer  after  layer  of  coagu- 
lum  ;  absorption,  first  of  adjacent  parts,  and  next  of  the  anexmsmal  sac  it- 
self.    Then  one  of  the  following  terminations  : 

Terminations. — 1  (most  common),  rupture  of  sac  and  death  ;  2,  escape 
of  piece  of  clot,  embolism  beyond  aneurism,  and  spontaneous  cure  ;  3, 
suppuration  of  sac  ;  4,  flow  of  blood  through  aneurism  checked  by  its  owu 
growth  and  pressure  on  artery  above  ;  5,  coagulation  may  go  on  to  so 
great  an  extent  as  to  fill  sac  with  fibrinous  lamime,  and  stop  jDulsation  and 
furtlier  enlargement ;  6,  the  condition  may  i-emain  stationary.  All  these 
events,  except  the  first  and  sixth,  may  cause  spontaneous  cure.  But  the 
third  may  cause  fatal  hemorrhage.  Aneurisms  burst  through  serous  mem- 
branes with  a  large  opening,  causing  instant  death  ;  but  through  mucous 
membrane  and  skin  with  a  small  opening,  so  that  death  is  preceded  by 
several  hemorrhages. 

Treatment. — Classified  into  internal  or  medical,  and  external  or  surgi- 
cal. Every  method  aims  at  producing  a  clot  which  shall  stop  the  growth 
of  the  aneurism,  excepting  the  method  of  Antyllus.  Surgical  treatments 
are  :  1,  ligature  (Anel's,  Hunter's,  and  Brasdor's  operations)  ;  2,  pressujfe 
(instrumental  and  digital)  ;  3,  flexion ;  4,  use  of  Esmarch's  bandage 
(Reid)  ;  5,  acupressure  and  temporary  ligature  ;  6,  manipulation ;  7,  gal- 
vano-puncture  ;  8,  coagulating  injections  ;  9,  wire  in  the  sac. 

Ligature — Method  of  Antyllus. — Operation. — Command  artery  above 
aneurism.  Open  sac  and  turn  out  clots.  Find  the  arterial  orifices  open- 
ing into  it,  and  tie  the  artery  above  and  below  aneiu-ism,  controlling  hem- 
orrhage in  the  meantime  by  pressure  with  the  fingers.  When  suitable  : 
1,  in  gluteal  aneurisms  ;  2,  axillary  aneurisms  ;  3,  traumatic  aneurisms  at 
bend  of  elbow ;  4,  when  an  aneurism  has  been  opened  accidentally  ;  5, 
when  the  sac  has  burst. 

Hunterian  Operation. — Arteiy  tied  at  point  of  selection  above  aneurism. 
— Operation. — Instruments:  scalpel,  forceps,  retractors,  artery-forceps,  liga- 
tures, aneurism-needle,  etc.  Observe  landmarks,  incise  or  separate  stmc- 
tures  to  expose  sheath  of  vessel,  make  a  very  small  opening  in  the  sheath, 
gently  separate  artery  from  sheath  at  point  selected.  Pass  aneurism-needle 
from  the  side  where  vein  lies.  The  great  advantages  of  Hunter's  opera- 
tion are  that  artery  is  most  likely  to  be  healthy,  and  certain  to  be  accessi- 
ble, at  the  pari  chosen. 

Anel  tied  the  artery  immediately  above  the  aneurism. 

Brasdor's  Operation. — Artery  tied  on  the  distal  side  of  aneurism. 
Chiefly  applicable  to  carotid  in  aneurisms  at  root  of  neck. 

Pressure. — Either  (1)  direct,  i.e.,  upon  the  aneurism  itself — very  unu- 
sual ;  or  (2)  upon  the  artery.  Effected  either  by  the  fingers  or  by  mechan- 
ical contrivances,  e.g.,  Carte's  tourniquet,  or  P.  H.  Watson's  weight  com- 


16  ANEUKISM. 

pressor.  The  treatment  by  Esmarch's  bandage  should  be  classed  as  a 
treatment  by  pressure.  Under  anaesthesia  almost  any  aneurisms,  except 
the  thoracic,  may  be  treated  by  compression  ;  and  certain  thoracic  aneu- 
risms might,  perhaps  with  advantage,  be  treated  by  distal  compression  of 
tlie  carotid,  etc.,  on  the  principle  of  Brasdor's  operation.  Statistics  of  re- 
sults much  better  than  those  of  ligature.  But  prolonged,  unsuccessful 
compression  sometimes  ajDpears  to  make  worse  the  prognosis  of  a  subse- 
quent operation  for  ligature. 

Prepare  the  patient  by  rest  in  bed  and  limited  diet  (both  as  to  fluids 
and  soUds).  Chloral  if  necessary.  Bandage  limb,  shave  seat  of  pressure 
and  dust  it  with  hair-powder.  If  pressure  be  instrumental  and  there  be 
room,  apply  two  instruments  to  the  artery  and  use  them  alternately.  Keep 
bed-clothes  well  off  the  tourniquets.  Patient  may  sometimes  be  instructed 
to  manage  his  own  treatment.  Anodynes  if  necessary.  Use  the  minimum 
pressure  absolutely  necessary  to  check  the  flow  of  blood.  Keep  it  up  con- 
tinuousl}^,  even  during  sleep,  if  the  patient  can  be  got  to  bear  it.  In  com- 
pressing the  abdominal  aorta  or  the  Hiacs,  it  is  best  to  produce  anaesthesia 
and  keep  it  up  for  hours.  Aneurisms  may  thus  be  cm-ed  by  one  spell  of 
compression. 

Digital  compression  requires  relays  of  assistants.  A  weight  should  be 
suspended  so  as  to  press  down  on  the  assistant's  fingers,  and  supply  the 
compressive  force.  Duration  of  pressure  treatment  very  variable — often  a 
month  ;  in  some  cases  cure  has  resulted  in  a  few  hours. 

Many  valuable  papers  on,  and  cases  of  treatment  of  aneurism  by  com- 
pression, are  to  be  found  in  the  Dublin  Medical  Journal. 

3.  Flexion. — Especially  applicable  to  aneiuisms  situated  in  the  flexures 
of  joints,  e.g.,  popliteal,  and  on  the  superficial  aspect  of  the  artery.  Bend 
the  Hmb,  not  too  acutely  at  first,  and  fix  it  thus  with  straps,  buckles,  or 
bandages.  Rest  in  bed  and  restricted  diet  as  accessories.  Slight  simulta- 
neous compression  of  artery  above  sometimes  advisable.  (See  Ei'nest  Hart : 
"  Medico-Chirurgical  Transactions,"  vol.  xlii.,  p.  405.) 

4.  Esmarch's  bandage  should  be  applied  imder  anaesthesia,  and  may  be 
kept  on  for  two  hours  or  more.  But  one  application  for  one  hour  has 
sometimes  been  found  quite  sufficient.     (Dr.  W.  Reid,  R.N.) 

Notes  on  Special  Aneurisms. — Aorta,  Aneurism  of — Thoracic. — See 
medical  works.  Usually  treated  by  rest  and  restricted  diet  (Tufnell's  treat- 
ment). Galvano-puncture  and  distal  ligature  {i.e.,  of  the  carotid)  have 
both  been  employed  beneficially. 

2.  Abdominal  Aneurism. — May  be  either  of  aorta  or  of  one  of  its 
branches.  Diagnose  from  "hysterical  pulsation,"  from  pulsating  cancer, 
and  from  abscess.  In  hysterical  pulsation  there  are  no  true  aneurismal  bruit 
and  no  tendency  to  progress,  but  there  are  concomitant  signs  of  nervous 
disorder.  The  other  sources  of  en-or  may  be  avoided  by  applying  general 
principles,  and  watching  a  doubtful  case  for  a  short  time.    Treatment  must 


ANKYLOSIS.  17 

generally  be  medical ;  but  success  has  attended  compression  of  abdominal 
aorta  under  anaesthesia  for  several  hours  (Murray :  "  Medico-Chirurgical 
Transactions,"  vol.  xlvii.).  Directions  for  tying  the  iUac  arteries  will  be 
found  under  Arteries. 

Axillary  Aneurism. — Generally  treated  by  ligature  of  subclavian  (third 
part).  Compression  of  subclavian.  Operation  of  AntyUus  recommended 
by  Syme.  « 

Carotid  Aneurism. — Commonest  seat — bifurcation  of  common  carotid. 
When  seated  at  root  of  neck,  tie  distally  (Wardrop's  and  Brasdor's  opera- 
tion). 

Femoral  Aneurism. — Comparatively  common,  and  admirably  suited  for 
treatment  by  compression.  If  ligature  is  resorted  to,  external  ihac  must 
be  tied  for  aneurism  of  common  femoral. 

Gluteal  Aneurism. — Usually  traumatic,  and  singularly  liable  to  be  mis- 
taken for  abscess.  Suitable  cases  for  such  treatment  as  galvano-puncture. 
"  Many  cases,  I  have  no  doubt,  might  be  cured  by  compression  of  the  aorta 
or  common  iliac  artery  under  chloroform." — Holmes.  Compression  per 
rectum  might  be  also  suggested.     See  also  Holmes,  Lancet,  July  11,  1874. 

Orbital  ^Aneurism. — Usually  common  aneurism,  but  very  exceptionally 
"  cirsoid."  Symptoms. — Besides  pulsation,  there  are  displacement  of  the 
eyeball  and  loss  of  sight.  Treatment. — Spontaneous  cure  possible.  Com- 
press carotid  digitally.  Other  treatment  dangerous,  but  may  be  unavoid- 
able. Ligature  would  have  to  be  ajjplied  to  the  common  carotid.  Refer 
to  Rivington  :  "  Medico  Chirurgical  Transactions,"  vol.  Iviii. 

Subclavian  Aneurism. — Ligature  of  the  innominate  and  of  the  first  part 
of  the  subclavian  artery  have  been  always  fatal,  excepting  in  one  case. 
Therefore,  subclavian  aneurism  is  best  adapted  for  the  diet  and  rest  treat- 
ment, or  for  galvano-puncture,  or  for  manipulation.  Amputation  at  the 
shoulder-joint  is  in  some  cases  justifiable.  "Willett  has  suggested  a  com- 
bination of  amputation  at  the  shoulder-joint  with  ligature  of  the  carotid. 

Ankle-Joint,  Disease  of. — Swelling  causes  prominence  of  and  fluctu- 
ation beside  extensor  tendons.  Diagnose  from  disease  of  tarsus.  In  the 
latter  case  there  is  free  movement  at  the  ankle  under  ansesthetics.  Prog- 
nosis is  the  more  favorable  because  general  exercise  can  be  combined  with 
local  rest. 

Ankylosis. — Three  kinds  :  1,  extra-articular  fibrous  ;  2,  intra-articular 
or  ordinary  Ji6roMS  or  false  ankylosis  ;  and  3,  bony  or  true  ankylosis.  In  the 
first  case  there  are  not,  in  the  second  there  are,  fibrous  bands  within  the 
joint.  First  case  results  from  inflammatory  thickening  of  surroandiug 
parts,  contracted  ligaments  and  tendons,  etc.  Often  there  is  a  combina- 
tion of  all  three.  Diagnosis. — In  osseous  ankylosis  there  is  no  motion 
whatever  ;  in  intra-articular  fibrous  there  is  some  motion,  which  is  checked 
more  abruptly  than  in  extra-articular.  An:esthetics  may  be  required. 
Say  re  tries  to  move  the  joint  vigorously  for  two  minutes  under  chloroform. 


18  ANTRUM,    DISEASES    OF. 

If,  within  twenty-four  houi-s,  any  swelling  result,  the  ankylosis  is,  of  course, 
not  bony.  Catises. — Joint-disease,  etc.  Osseous  ankylosis  usually  caused 
by  traumatic  disease.  Treatment. — 1,  Preventive  :  proper  passive  motion 
applied  in  time.  If  ankylosis  is  inevitable,  select  the  best  position ;  2, 
Cvu*ative : 

1.  Fibrous  Ankylosis. — Passive  motion,  friction,  douches,  steam-baths, 
^crew- splints,  weights.  Anaesthetics  :  subcutaneous  ruptui-e.  Take  a  short 
hold  (near  the  joint),  and  try  to  rupture  by  flexion.  Tenotomy.  Division 
of  tight  fascia. 

2.  Osseous  Ankylosis. — Do  not  interfere,  if  possible.  Fresh  disease 
may  be  excited,  or  the  operation  may  be  fatal.  "  Subcutaneous  resection." 
Sawing,  drilling,  fracturing  ;  cutting  out  wedge-shaped  piece  of  bone  ; 
fracturing  shaft  of  bone  just  below  joint.  Little  more  than  a  good  position 
usually  aimed  at. 

Antiseptic  Treatment,  The. — Almost  always  means  Lister's  method 
only.  Principles. — 1,  an  open  wound  does  worse  than  a  subcutaneous 
wound,  because  atmospheric  germs  enter  it  and  produce  fermentation,  re- 
sulting in  irritation,  decomposition,  etc.,  which  again  lead  to  inflammation, 
blood-poisoning,  etc.  ;  2,  certain  substances,  e.g. ,  carbolic  acid,  destroy 
these  germs.  Details. — Spray,  carbolized  instruments  and  hands,  carbolized 
catgut,  protective  next  wound,  gauze  (usually  eight  folds),  mackintosh  just 
beneath  uppermost  layer  of  gauze.  Sometimes  use  a  di-ainage  tube,  then  its 
end  must  be  well  concealed  by  gauze.  Carbolized  bandage,  elastic  band- 
age in  certain  cases,  safety-pins.  Exi^lanation  of  details. — Sj)ray  (strength 
1-40);  carbolizing  the  hands,  etc.,  prevents  access  of  live  germs  ;  protective 
protects  from  the  irritating  properties  of  carbolic  acid  ;  gauze  absorbs  and 
disinfects  discharge  ;  mackintosh  prevents  discharge  from  soaking  through 
to  the  surface,  and  thus  establishing  a  channel  of  disinfection.  Lotion  for 
washing  instruments,  etc.  (strength  1-40).  Dressing  should  be  removed 
under  spray  and  redone  from  time  to  time,  according  to  amount  of  dis- 
charge, which  should  not,  if  possible,  be  allowed  to  soak  quite  through. 
In  absence  of  spray -producer,  and  in  the  case  of  accident  wounds,  wash  the 
surfaces  with  lotion  (1-40).  Antiseptic  "  veil "  and  irrigation,  substitutes 
for  spray.  Boracic  and  saheylic  acid,  thymol,  and  ol.  eucalypti  have  been 
used  instead  of  carbolic  acid.  Strength  of  lotion  for  use  in  steam  spray- 
producer,  1-20  ;  steam  dilutes  it  to  1-40. 

Antrum,  Diseases  of,  may  be  classified  into  Cystic  Disease  of.  Sup- 
puration in,  and  Tumors  of  Antrum. 

Antrum,  Cystic  Disease  of.^ — Firstly,  there  is  the  form  known  as  Dropsy 
of  the  Antrum,  not  owing  to  obstruction  of  antro-nasal  orifice,  but  to  cystic 
disease  of  the  mucous  membrane  ;  simple  or  multiple  cysts  ;  bulging  into 
nose,  mouth,  orbit,  and  cheek  ;  thinning  of  bone,  even  to  crackling.  Con- 
tents :  thin,  brownish,  serous,  with  cholesterine.  Treatment. — Catheterize 
through  nose,  or  tap  through  anterior  wall  from  mouth,  or  di-aw  a  diseased 


ANUS.  19 

tooth  and  tap  through  its  socket.  Eestore  shape  of  cheek  by  pressure  with 
a  pad.  A  second  variety,  called  "  Bentigerous  Cysts,"  connected  with  mal- 
placed  teeth.  Small  ones  common.  Large  ones  cause  absorption  of  neigh- 
boring parts.  Treatment. — Open  and  remove  the  contained  teeth  ;  stuff 
cavity  with  Hnt  till  it  begins  to  granulate.  If  cyst  be  large,  remove  pai't 
of  its  wall. 

AifTRUM,  Suppuration  OF. — Causes. — Carious  teeth,  blows.  Sigiis. — Swell- 
ing, pain,  puffiness  of  neighboring  soft  parts  ;  perhaps  escape  of  pus  into 
nose.  Treatment. — Remove  the  offending  tooth  and  perforate  through  its 
socket,  or  extract  second  molar,  or  perforate  canine  fossa  with  a  carpenter's 
gimlet.  Wash  out  with  Condy  or  carboHc  lotion.  Keep  a  free  exit  for  the 
pus.     Restore  symmetry  by  pressure. 

Antrum,  Tumors  of,  include,  strictly,  above-mentioned  cysts;  also  fi-. 
brous,  sarcomatous,  osseous,  cartilaginous,  fatty,  erectile,  and  carcinoma- 
tous (epithelial  and  encephaloid) ;  fourth,  fifth,  and  sixth  kinds  very  rare. 
Diagnosis  practically  has  only  to  be  made  between  (1)  simj)le  and  (2) 
malignant  disease  ;  or  between  (1)  malignant  and  within  the  antrum,  and 
(2)  mahguant  and  extending  beyond  the  antrum.  If  an  operation  is  pro- 
posed, it  should  also  be  determined,  if  possible,  where  the  tumor  began, 
e.g.,  behind  the  antrum  or  not.  In  doubtful  diagnosis  from  cysts,  deter- 
mine by  perforation.  Malignant  tumors  (1)  grow  rapidly,  (2)  early  affect 
submaxillary  glands,  (3)  protrude  early  into  neighboring  cavities,  forming 
a  fungus.  Point  of  Origin. — Tumors  of  malar  bone  spread  over  upper 
jaw ;  intra-antral  tumors  expand  it  on  all  sides  ;  post-antral  tumors  jjush 
it  bodily  forward  -without  distorting  it.  Treatment. — Operative  or  pallia- 
tive. Question  of  operation. — If  the  soft  structures  of  the  cheek  are  not 
freely  movable  over  the  tumor,  and  if  the  glands  are  affected,  do  not 
operate  ;  nor  if  disease  be  malignant,  advanced,  and  post-antral  in  origin. 
In  simple  disease  remove  no  more  of  the  maxilla  than  the  side  diseased. 
For  the  operation,  vide  Excision  of  Upper  Jaw. 

Anus,  Artificial. — See  Colotomy. 

Anus,  Cancer  of,  usually  spreads  from  rectum.  If  primary,  commonly 
epitheUoma.     May  be  excised  at  first.     See  Cripps  on  Cancer  of  Rectum. 

Ano,  Fistula  in, — Causes. — It  is  the  sinus  left  by  an  ischio-rectal 
abscess,  quod  vide.  Varieties  and  Signs. — Complete  and  incomj)lete,  former 
opens  both  inside  and  outside  anus  ;  blind  internal  and  bUnd  external. 
Sometimes  there  are  several  openings  ;  outer  opening  usually  within  one 
inch  of  anus  ;  granulation  often  projecting  from  it  ;  coiu'se  of  fistula  feels 
hardened  and  thickened ;  purulent  discharge ;  tenderness ;  history  of 
former  abscess ;  constitution  often  phthisical.  Prognosis. — Permanent 
cure  difficult  if  the  openings  be  numerous  and  phthisis  coexist.  Ordinary 
cases  easily  remedied.  Treatment. — Introduce  first  a  probe,  then  a  direc- 
tor. Make  bUnd  fistula  complete.  Then  sht  up,  on  the  director,  the 
bridge  of  skin  and  sphincter  covering  fistula.     Precede  operation  with  a 


20  ANU3. 

purge  and  an  enema.  Dress  with  oiled  lint,  pad,  and  T-bandage.  Check 
severe  hemorrhage  with  styptics  and  pads.  Galvanic  cautery.  Ligatiire. 
Elastic  ligature.  Coexistence  of  phthisic  does  not  usually  contraindicate 
operation. 

Anus,  Fisstike  of,  usually  accompanied  by  Anal  Ulcer.  Causes. — Female 
sex:  debihty,  cachexia,  du'ty  habits,  eczema.  Signs. — Bm-ning  pain  after 
defecation,  sometimes  lasting  for  houi'S  ;  seat  of  pain,  chiefly  sacro-ihac 
articulation  ;  genito-urinary  initation  ;  purulent,  bloody  and  mucous  exu- 
dation ;  patient  feels  and  looks  worn  and  despondent ;  on  examining  anus 
carefully  (a  speculum  may  be  required),  one  or  more  small  ulcers  or  fis- 
sures seen,  generally  very  tender  ;  sphincter  very  irritable  and  spasmodic  ; 
ulcer  usually  near  coccyx  and  just  within  anus.  Treatment. — Cleanhness  ; 
.soap  and  water ;  zinc  ointment ;  glycerine  of  tannin  ;  nitrate  of  silver  ; 
anodyne  and  astringent  suppositories ;  division  of  ulcer  or  fissure  and 
supei-ficial  fibres  of  sphincter  to  depth  of  one-eighth  of  an  inch.  Eest  in 
bed  for  some  time  after  operation. 

Anus,  Imperforate  (including  congenitally  malformed  rectiun). — Six 
kinds.  Case  1.  Congenital  narrowness  of  anus.  Treatment. — Notch  and 
introduce  sponge-tents.  Case  2.  Complete  closure  of  anus ;  rectum  nor- 
mal. Treatment. — Crucial  incision  ;  no  plug  required.  Case  3.  Closure 
of  rectum  by  a  membranous  septum  ;  anus  normal.  Treatment. — Pass  au 
ear-speculum  up  to  the  septum  ;  pass  a  tenotomy-knife  through  speculum, 
and,  cutting  in  the  median  line,  with  an  inchnation  toward  the  sao'uvi, 
divide  the  septum.  Case  4.  Complete  absence  of  anus.  Case  5.  Ab- 
sence of  a  considerable  part  of  the  rectum  ;  often  a  fibrous  cord  instead. 
Treatment. — In  Cases  4  and  5  an  attempt  may  be  made  to  dissect  up  to  the 
rectum  as  follows  :  Oiieration. — Keej)  in  mind  small  size  of  pelvis  and 
relations  of  bladder  and  internal  iUac  vessels  ;  empty  bladder  ;  incise 
exactly  in  the  position  of  the  anal  depression  ;  crucial  incision  ;  cut  be- 
yond the  posterior  margin  of  the  depression  ;  cut  deeply  with  first  inci- 
sion ;  introduce  finger  with  the  point  upward  and  backward.  Generally  the 
cul-de-sac  of  the  bowel  can  be  felt  when  the  child  cries,  or  when  the  abdo- 
men is  pressed  upon  by  the  assistant.  Punctui-e  uj)ward  and  backwai'd  ; 
enlarge  with  probe-pointed  bistoury  ;  bring  mucous  membrane  of  gut 
down  to  external  wound,  if  possible  ;  keep  open  at  first  with  a  suppository. 
If  the  operation  fails,  never  plimge  a  shai-p  instrument  blindly  into  the 
pelvis,  but  perform  Littre's  operation.  Vide  Colotomy.  Case  6.  Kectum 
may  communicate  with  or  open  into  vagina,  bladder,  or  lu-ethra.  Treat- 
ment for  Case  6. — Plastic  operation  ;  operation  for  artificial  anus ;  or  nil. 
Colotomy  sometimes  causes  a  mere  communication  to  close  up,  and  all  the 
faeces  to  pass  per  anum. 

Ani,  Prolapsus,  is  really  a  prolapse  of  rectum,  usually  of  its  mucous 
coat  only.  Causes. — Constitutional  weakness.  Kectal,  genital,  and  uri- 
nary irritation  causing  straining.     Piles.     Polypi,  urinary  calcuh,  worms, 


ARTEEIES.  21 

phimosis,  constipation.  Age  of  childhood.  Signs. — Protrusion  of  a  ring 
of  mucous  membrane,  becoming  dark  and  turgid  if  allowed  to  remain  pro- 
lapsed. Strangulation,  suppuration,  and  even  mortification  may  occur. 
Treatment. — Eeduce  prolapse  at  once.  Regulate  bowels  ;  mild  aperients, 
Friedrichshall  water,  "  effervescing  citrate  of  magnesia."  Eecumbent  posi- 
tion after,  or  even  during  defecation.  Astringent  injections,  alum,  tannin, 
iron.  Tonics,  iron,  str'ychnia.  Always  seek  for  and  remove  cause.  In 
bad  cases,  ligature  parts  of  the  prolapsus,  or  paint  it  with  strong  nitric 
acid,  bathing  afterward  in  cold  water.  Incise  freely  a  strangulated  pro- 
lapsvis.  Children  should  have  one  buttock  pulled  to  one  side  obliquely 
during  defecation.     This  causes  a  tight  fold  of  skin  to  support  anus. 

Arteries,  Atheroma  of. — Term  ajoplied  to  the  effect  produced  on 
arteries  by  a  chronic  or  subacute  inflammation.  Causes. — In  many  cases, 
unknown.  Alcohol,  syphilis.  Common  in  advanced  age.  Atheroma  is 
common  where  an  artery  pulsates  against  a  bony  surface  (A.  Barker). 
Signs. — During  life  such  arteries  as  the  radial  and  temporal  are  often 
found  hardened  and  even  looped.  Liability  to  aneurisms  and  rupture  of 
the  arteries.  Pathology. — Begins  by  a  deposit  of  cells  in  the  inner,  where 
it  joins  the  middle  coat.  This  inflammatory  new  formation  takes  one  of 
three  courses  :  either  (1)  it  softens  down  into  molecules  and  fat  and 
causes  an  ulceration  of  the  tunica  intima  ;  or  (2)  it  organizes  into  a  fibrous 
thickening ;  or  (3)  it  undergoes  a  calcareous  degeneration.  It  is  in  the 
first  case  that  aneurism  is  most  likely  to  occur.  In  the  smaller  vessels  it 
is  the  muscles  which  ossify.  When  the  disease  attains  a  high  grade,  the 
arteries  bulge  out,  various  stages  found  together  at  same  time.  In  the 
smallest  arteries  the  process  affects  chiefly  the  adventitia.  In  the  largest 
arteries  (which  are  almost  void  of  muscle)  it  affects  almost  entirely  the 
intima.  Atheroma  pulp  consists  of  molecular  and  fat  grantiles,  cholester- 
ine,  crumbs  of  carbonate  of  lime,  and  huematoidin  crystals.  Effects  of 
Atheroma. — Secondary  hemorrhage.  (Acupressure  recommended  for  athe- 
romatous arteries.)     Gangrene.     Aneurism. 

Aeteries,  Ligature  of. — Arteries  are  tied  either  in  the  continuity  or  at 
a  point  wounded  or  severed.  1.  Ligature  in  the  Continuity. — OiDcration 
generally  done  at  a  point  selected,  because,  1,  it  is  not  too  near  a  diseased 
part  of  the  vessel  {e.g.,  an  aneurism)  ;  2,  it  is  not  so  far  off  an  aneurism 
that  collateral  circulation  would  at  once  nullify  the  operation  ;  3,  it  is  not 
close  to  the  origin  of  a  large  branch,  the  rush  of  blood  through  which 
would  prevent  coagulation  and  cause  secondary  hemoi'rhage.  Operation. 
— Learn  well  the  superficial  and  deep  landmarks,  and  the  anatomy  of  the 
part.  Mark  out  the  vessel's  course.  Incise  the  skin  and  superficial  fascia 
equally  and  sufficiently.  A  director  may  be  used  for  the  deep  fascia. 
Avoid  superficial  veins  ;  avoid  opening  sheaths  of  muscles.  "  The  surgeon 
should  not  at  the  commencement  occupy  himself  with  looking  for  the 
artery,  but  should  seek   the  first  marked  point   of  guidance,   then  the 


22  ARTERIES. 

second,  then  the  third,  and  so  on  to  the  end  "  (Bryant).  Handle  of  knife 
will  push  muscles,  etc.,  aside.  Retractors.  Feel  artery  pulsate.  Open- 
ing in  sheath  to  be  small,  and  made  with  knife-blade  held  on  a  plane  just 
sujierncial  to  the  artery,  that  is,  "on  the  flat."  Insinuate  aneurism-needle 
round  artery.  Draw  out  ligature  with  forceps.  In  tying,  press  down 
knot  with  tips  of  foi-efingers  ;  do  not  lift  vessel  from  its  bed.  Cut  one 
end  of  a  silk  ligature  short,  and  both  ends  of  a  catgut  one.  Close  wound 
and  dress.  Before  actually  tying  ligature,  make  sure  that  you  have  sur- 
rounded the  artery,  the  whole  artery,  and  nothing  but  the  artery.  Needle 
should  be  passed  between  the  artery  and  its  vein.  Process  of  Repair,  etc. — 
The  two  inner  coats  are  divided  by  the  ligature  and  retract  a  httle.  A  clot 
forms  up  to  the  nearest  branch.  Lymph  is  effused  around  the  ligature. 
In  the  most  favorable  cases  the  lymph  and  the  clot  organize  ;  and  the  cut 
arterial  coats  grow  together,  so  that  when  the  outermost  coat  is  ulcerated 
thi'ough,  a  new  bariier  has  been  formed  against  hemorrhage.  But  these 
processes  may  whoUy  or  partially  fail.  Then  there  is  more  or  less  danger 
of  secondary  hemorrhage.  Dangers. — Secondary  hemorrhage  from  above 
cause,  or  fi'om  suppuration.  Gangrene,  from  non-estabUshment  of  collat- 
eral cii'culation,  from  injury  to,  and  consequent  coagulation  in,  the  vein, 
or  from  suj^puration  of  an  aneurismal  sac.  Erysipelas  and  other  accidents 
to  which  all  wovmds  are  liable.  2.  Ligature  of  an  Artery  open  in  a  Wound. 
— Be  careful  not  to  include  neighboring  nerve.  Reef-knot.  Hemp,  silk, 
and  catgut  ligatures.  Cai'bolized  catgut  is  absorbed  or  organized,  and 
scarcely,  if  at  aU,  acts  like  a  foreign  body  in  the  wovmd.  One  end  of  a 
hemp  or  silk  ligature  must  be  left  hanging  out  of  the  wound. 

Axillary. — Very  rarely  tied.  Line  of  artery.  From  just  internal  to 
coracoid  process,  cur\dng  outward  and  downward  to  commencement  of 
brachial  artery.  Divide  skin  and  pectoralis  major.  Beware  of  vein  and 
brachial  plexus. 

Ligature  of  Special  Arteries. — Abdominal  Aorta. — 1st  method  :  incise 
the  abdominal  wall  as  in  ovariotomy.  Divide  the  peritoneum  covering  the 
aorta,  and  pass  the  ligature.  2d  method  :  make  an  incision  like  that  for 
ligature  of  common  ihac,  and  proceed  as  if  for  ligatui*e  of  that  vessel,  but 
keep  a  httle  higher.  Doubtful  whether  operation  is  ever  justifiable.  For 
details,  vide  larger  works. 

Brachial. — In  middle  of  upper  arm.  Line  of  incision,  inner  edge  of 
biceps.  Avoid  basilic  vein  and  internal  cutaneous  nerve  ;  open  deep  fas- 
cia ;  look  out  for  median  nerve  ;  artery  usually  lies  just  beneath  it,  but 
may  be  superficial  to  it.     Remember  occasional  high  division  of  brachial. 

Carotid,  Common. — Position :  head  back,  face  turned  away  at  first. 
Place  of  selection  :  just  above  omo-hyoid  {i.e.,  level  of  cricoid  cartilage). 
Line  of  artery,  sterno- clavicular  articulation  to  midway  between  mastoid 
process  and  angle  of  jaw  ;  incise  skin  along  anterior  border  of  sterno- 
mastoid  three  inches  ;  platysma  ;  deep  fascia.     Raise  head,  relax  and  re- 


ARTERIES.  28 

tract  sterno-mastoid  ;  look  for  omo-liyoid  ;  carotid  sheath  with  descendens 
noni.  As  a  rvde,  jugular  vein  and  vagus  nerve  not  seen.  2.  In  tying 
artery  low  down,  divide  partially  sterno-mastoid,  sterno-hyoid,  and  stemo- 
th^T-'oids.  Fatality. — 40  per  cent. :  in  ordinary  cases  one  in  three.  When 
operation  is  for  hemoi-rhage,  56  per  cent.  die.  "When  for  aneurism,  on 
Brasdor's  method,  only  one  in  four.  For  affections  of  the  nervous  system, 
only  one  in  thirty-four.  Chief  Dangers. — Brain  symptoms  and  secondary 
hemorrhage. 

Carotid,  External  and  Internal. — Ligature  of  common  carotid  preferred. 
For  external  carotid  proceed  as  follows  :  hne  of  incision  same  as  for  com- 
mon carotid  ;  incision  from  angle  of  jaw  to  thyroid  cartilage  ;  freely  incise 
any  glands  which  may  be  in  the  way  ;  tie  and  divide  cutaneous  veins  ; 
look  for  hypoglossal  nerve  ;  tie  the  artery  between  origins  of  supra-thyroid 
and  hngual  arteries. 

Femoral. — The  common  femoral  rarely  tied ;  ligature  of  external  iliac 
preferred.  Incise  in  line  of  artery  ;  crural  branch  of  genito-crural  nerve  ; 
open  sheath  ;  tie  about  one  inch  below  Poupart's  ligament  ;  pass  needle 
from  within  outward. 

Superficial  femoral  tied  in  two  places  :  1.  At  apex  of  Scarpa's  triangle. 
Position  :  abduction  and  rotation  outward  ;  knee  flexed  ;  line  of  arter}', 
from  middle  of  Poupart's  ligament  to  front  of  inner  condyle  ;  incise  skin 
3-4  inches  at  junction  of  upper  and  middle  thirds  of  thigh  ;  divide  fat ; 
avoid  saphena  vein  ;  divide  fascia  lata  well  to  inner  side  of  sartorius,  so 
as  not  to  open  sheath  of  that  muscle  ;  retract  sartorius  outward  ;  feel  for 
sheath  of  artery  ;  branch  of  ant.  crui-al  over  sheath  ;  open  sheath ;  clean 
ai*tery  with  point  of  director  ;  pass  needle  from  inner  side.  2.  In  Hun- 
ter's canal.  Done  when  operation  in  Scarpa's  triangle  fails.  If  done  at 
lower  end  of  Hunter's  canal,  draw  sartorius  to  inner  side  ;  incision  in  the 
same  line  as  when  artery  is  tied  in  Scarpa's  triangle,  but  longer,  and  of 
course  lower  down  thigh.  Other  steps  similar  to  first  operation.  Fatal- 
ity.— One  in  four.  Syme  was  successful  twenty-three  times  in  suc- 
cession. 

Iliac,  Common. — Line  of  artery  :  from  half-inch  to  left  of  umbihcus  to 
middle  of  Poupart's  ligament.  Incision,  from  end  of  last  rib  downward 
and  forward  to  crista  ilii,  and  then  forward  above  and  parallel  to  crest  of 
ihum  as  far  as  anterior  superior  spine  ;  divide  muscles  and  transversalia 
fascia,  using  finger  as  a  director  ;  roll  up  peritoneum  and  intestines  out  of 
way,  and  tie  artery.  Second  method  :  incise  skin  first  from  outside  in- 
ternal abdominal  ring,  parallel  to  Poupart's  ligament,  three  or  four  inches 
toward  ant.  sup.  spine  of  ilium  ;  then  continue  incision  with  a  curve  in- 
ward toward  umbilicus,  and  proceed  with  muscles  and  transversalis  fascia 
much  as  in  first  method.  Remember  relation  to  veins,  ureter,  and  sper- 
matic vessels.  Fatality. — Very  great — twenty-five  in  thirty-two!  Chief 
causes  :  exhaustion  and  hemorrhajje. 


24  AETEKIES. 

Iliac,  External. — Line  of  artery  same  as  common  iliac.  Incise  skin  half 
an  inch  above  Poupart's  ligament  from  just  external  to  internal  abdominal 
ring  outward  in  a  curve  three  inches  long  and  parallel  to  the  ligament ; 
divide  muscles  and  transversalis  fascia  carefully  ;  push  up  peritoneum  ; 
separate  artery  from  vein  ;  pass  needle  from  within  outward  ;  the  higher 
up  the  artery  is  to  be  tied,  the  farther  must  the  outer  end  of  the  incision 
be  extended  upward  and  inward,  the  incision  thus  becoming  like  that  for 
the  common  iliac.  Beware  of  seven  dangers  :  1,  wound  of  epigastric  ar- 
tery ;  2,  wound  of  spermatic  cord ;  3,  laceration  of  peritoneum  ;  4,  punc- 
ture of  external  iliac  vein  ;  5,  of  circumfiexa  ilii  vein  ;  6,  ligature  of  genito- 
crural ;  7,  too  free  disturbance  of  subperitoneal  cellular  tissue.  Fatality. 
— One  in  three.     Chief  causes :  gangrene,  hemorrhage,  and  peritonitis. 

Iliac,  Internal. — Steps  of  operation  as  for  common  iliac.  Trace  inter- 
nal iliac  from  bifurcation  of  common  iliac  ;  scratch  artery  clean  with  finger- 
nail and  director  ;  pass  ligatiu'e  three-quarters  of  an  inch  from  origin. 
Beware  of  ureter,  vein,  and  peritoneum.     Fatality. — One  in  two. 

Innominate. — Incision  along  anterior  border  and  sternal  end  of  sterno- 
mastoid  ;  divide  as  much  of  sterno -mastoid  as  may  be  necessary  to  expose 
carotid,  and  trace  carotid  downward  to  innominate.  Fatality. — Only  one 
case  has  recovered.  In  it  the  carotid  and  vertebral  were  also  ligatured 
(Smyth's  case). 

Lingual. — Line  of  artery  :  just  above  greater  cornu  of  hyoid  bone  ;  in- 
cision horizontal,  with  centre  opposite  end  of  greater  cornu  of  hyoid  bone  ; 
look  for  hypoglossal  nerve  ;  ai-tery  crosses  beneath  it ;  divide  hyo-glossus 
muscle  from  hyoid  bone  :  artery  is  thus  exposed.  Object. — Usually  to 
check  hemorrhage  from  cancer  of  tongue. 

Radial. — Line  of  artery  :  fi'om  inner  side  of  biceps  tendon  at  bend  of 
elbow  to  half  an  inch  internal  to  styloid  process  of  radius.  Ligature  in 
upper  third :  incision  in  line  of  artery.  Separate  supinator  longus  from 
pronator  teres,  and  tie.  Lower  third  :  divide  skin  and  deep  fascia  to  outer 
side  of  flexor  carpi  radialis. 

Subclavian. — Tied  only  in  third  part  of  its  course.  Raise  patient  on 
a  piUow,  head  back,  face  tiu-ned  away,  arm  pulled  down  ;  incise  along 
clavicle,  ptdling  skin  down  over  it;  divide  border  of  sterno- mastoid  if  neces- 
sary ;  deep  fascia  ;  retract  external  jugular  ;  separate  vessels  and  cellular 
tissue  beneath  deep  fascia  without  using  knife  blade  ;  feel  for  scalene  tu- 
bercle and  scalenus  anticus.  Subclavian  lies  behind  them  ;  brachial  plex- 
us and  subclavian  vein ;  pass  needle  from  below  upward.  Fatality. — 
Nearly  one  in  two.  Chief  causes  :  hemorrhage,  gangrene,  intrathoracic 
inflammation,  "  sloughing  or  suppuration  of  aneurism." 

Tibial,  Anterior. — Line  of  artery:  from  head  of  fibula  to  midway  be- 
tween two  malleoli.  Upper  or  middle  third :  divide  skin  in  line  of  vessel ; 
look  for  a  white  Hue  in  deep  fascia,  marking  outer  border  of  tibialis  anti- 
cus ;    divide  the  line  and  separate  tibiahs  anticus  from  ext.  long.  dig. 


ASPHYXIA.  25 

above,  and  from  extensor  prop.  poll,  below  ;  nerve  superficial ;  patient 
should  put  tibialis  anticus  into  action  before  anaesthesia.  Lower  third  : 
artery  nearly  superficial. 

Tthial,  Posterior. — Upper  half:  two  methods — 1  (Guthrie's),  perpendicu- 
lar incision,  six  inches  long,  through  middle  of  gastrocnemius,  soleus  and 
deep  (submuscular)  fascia  ;  artery  lies  on  tibialis  posticus  ;  nerve  crossing 
superficially  and  obhquely  from  v^rithin  outward.  2d  method  :  incision, 
three-quarters  of  an  inch  behind  and  parallel  to  posterior  border  of  tibia, 
down  to  tibial  origin  of  soleus.  Separate  soleus  from  bone,  divide  sub- 
muscular  fascia,  and  find  artery  immediately  beneath  it. 

Near  Ankle. — Ai-tery  lies  beneath  thick  deep  fascia,  rather  nearer  mal- 
leolus than  heel.     Incise  over  it. 

Ulnar. — Line  :  from  middle  of  bend  of  elbow,  curving  inward  slightly, 
to  outer  side  of  pisiform  bone.  Upper  half:  incise  obliquely  over  course 
of  vessel  and  well  to  inner  side  of  arm  ;  find  outer  border  of  flex,  carpi 
ulnaris ;  divide  it  fr6m  flex,  sublimis,  and  find  artery  between  superficial 
and  deep  flexors  ;  inner  border  of  flexor  sublimis  may  be  found  in  thin 
people  by  putting  that  muscle  in  action. 

Above  Wriat. — Divide  skin  and  deep  fascia  just  outside  tendon  of  flex, 
carpi  ulnaris.     Nerve  on  the  inner  side. 

Asphyxia. —  Causes. — 1,  Compression  of  chest ;  2,  compression  of 
lungs  by  air  in  pleura  ;  3,  traumatic  compression  of  trachea,  as  in  garrot- 
ting ;  4,  foreign  body  in  air-passages  ;  5,  immersion  in  some  fluid,  in- 
cluding (a)  water  (drowning),  (6)  some  inert  gas,  (c)  some  poisonous  gas  ; 
6,  disease,  including  (a)  pressure  by  aneurism,  oedema  glottidis,  accumu- 
lation of  mucus,  etc.,  (h)  paralysis  of  respiratory  muscles.  Hanging  may 
be  classed  Avith  Cause  3.  Apjjeay^ances. — Lividity,  sweUing  of  face,  perhaps 
bleeding  from  nose  or  mouth.  Post-mortem  :  engorgement  of  right  side 
of  heart,  emptiness  of  left  side  of  heart ;  arteries  contain  venous  blood  ; 
abdominal  viscera  engorged  ;  lungs  not  peculiar  when  there  has  only  been 
mechanical  obstruction  ;  but  in  drowning  they  are  filled  with  frothy  water, 
doughy  and  heavy,  and  the  air-tubes  are  choked  with  frothy  and  bloody 
water  and  mucus.  Brain  sometimes  hypersemic,  especially  after  hanging 
or  suffocation.  Prognosis. — Almost  hopeless  after  five  minutes'  submer- 
sion. Kemember,  a  person  may  be  immersed  some  time  without  being 
submerged.  Kecoyery  has  taken  place  after  three-quarters  of  an  hour  of 
asphyxia  (Weeks).     Prognosis  much  worse  if  water  has  got  into  the  lung. 

Treatment. — In  drowning,  hold  the  patient's  head  downward  for  a  few 
seconds  to  begin  with.  In  hanging  or  choking,  bleed  from  jugular.  If 
there  is  obstruction  to  passage  of  air  through  mouth  or  nose,  open  trachea. 
Then  friction,  warmth,  warm  bath  (100°),  ammonia  to  nostrils  ;  but  begin 
at  once  artificial  respiration,  and  continue  it.  Artificial  respiration  by  1, 
inflation  from  mouth  to  mouth  ;  2,  bellows  ;  3,  split  sheet ;  4,  Marshall 
Hall's  method ;  5,  Sylvester's  ;  6,  Howard's ;  7,  inhalation  of  oxygen ;  8, 


26  BAR    AT   NECK    OF    BLADDER. 

galvanizing  phrenic  nerve.  With  bellows,  15  cubic  inches  should  be  in- 
troduced 12  times  a  minute.  Oxygen  was  successfully  administered  after 
three-quarters  of  an  hoxu-'s  asphyxia,  in  Weeks'  case. 

Sylvesters  Method. — Lay  body  on  back,  on  a  plane  inclined  slightly 
toward  feet ;  cushion  under  head  ;  head  in  line  with  trunk  ;  tongue  drawn 
forward  ;  grasp  arms  just  above  elbows  and  draw  upward  till  they  nearly 
meet  above  head  ;  there  retain  them  for  two  seconds  ;  then  depress  them 
again  and  press  them  firmly  for  two  seconds  against  the  sides,  combined, 
if  possible,  with  pressui-e  on  lower  part  of  sternum  ;  repeat  about  fifteen 
times  per  minute.  Remember,  artificial  respiration  is  to  be  attended  to 
the  first  thing  ;  warmth  and  friction  are  secondary  ;  the  endeavors  should 
be  kept  up  for  at  least  three  or  foui*  hours,  even  without  any  encour'aging 
signs. 

In  hanging,  besides  asphyxia,  there  is  usually  some  apoplexy  as  well  as 
injury  to  the  spinal  cord. 

Aspiration. — The  aspirator  is  an  exhausting  syringe,  used  for  drawing 
off  fluids  without  admitting  ingress  of  air,  and  in  exploring  for  purposes 
of  diagnosis.  The  needle  should  be  pressed  in  with  a  screwing  motion, 
and  the  taps  should  be  managed  carefully  and  without  hurry. 

Atheroma. —  Vide  Arteries,  Atheroma  of. 

Atheromatous  Tumors. —  Vide  Tumors  (Cysts). 

Back,  Sprains  of. — Usually  occur  in  neck  or  loins,  often  affect  intei*^ 
vertebral  Hgaments  ;  tumefaction,  rarely  ecchj'mosis,  stiffness,  tenderness  ; 
in  severe  cases,  patient  lies  on  his  side,  semi-flexed  ;  hsematuria  when  the 
kidneys  are  hiu't ;  occasionally  symptoms  of  paralysis  ;  if  such  persist,  in- 
travertebral  hemorrhage,  inflammation  of  the  meninges,  or  injury  to  the 
cord,  are  indicated.  Causes. — Falls  on  head  or  buttocks,  railway  collisions, 
Rugby  football,  etc.  Diagnosis. — From  fracture  or  dislocation,  line  of 
spinous  processes  straight ;  tenderness  more  or  less  diffuse  ;  patient  can 
probably,  though  with  pain,  raise  himself  into  the  erect  position,  straight- 
ening his  spine.  Prognosis. — Good,  even  when  there  is  hsematuria ;  even 
severe  pai'alysis  sometimes  passes  off  in  a  day  or  two,  but  danger  of  inflam- 
mation spreading  to  meninges  of  cord.  This  danger  is  greatest  in  atlanto- 
axial region.  See  Spinal  Meningitis,  Fracture,  Hemorrhage,  etc.  Treatment. 
— Rest.  See  Sprains.  Actual  cautery  and  Corrigan's  button  or  Sayre's 
jacket  in  obstinate  cases. 

Balanitis. — Inflammation  of  gians  penis  or  lining  membrane  of  pre- 
puce. Causes. — Gonorrhoea,  phimosis,  dirty  habits,  ill-health.  Treatment. 
— Warm  water,  zinc  ointment,  astringent  lotions,  nitrate  of  silver.  A 
chancre  may  coexist. 

Bar  at  Neck  of  Bladder. — Definition.—  "  Any  bar  "  at  the  inferior  as- 
pect of  the  neck  of  the  bladder,  and  not  prostatic  in  its  nature.  Extremely 
rare.  Treatment. — Relieve  accompanying  chronic  cystitis ;  occasionally 
pass  a  large  catheter.      Vide  Thompson  and  Guthrie.  ^ 


BITES    OF    POISONOUS    SNAKES.  27 

Barbadoes  Leg. — See  Elephantiasis  Arabum. 

Bath,  Continuous    Water-Bath,  or  Immersion   Treatment  of 

wounds  and  compound  fractures.  Temperature  varies  ;  cold  water  delays 
the  healing,  but  prevents  blood-poisoning ;  in  compound  fractures  the 
limb  is  placed  in  a  fenestrated  j^laster  case,  made  water-tight  with  shellac, 
cement,  or  collodion.     Used  at  Berlin. ' 

Bed-Sores  attack  the  skin  over  hard  prominences,  e.g.,  sacrum,  ischial 
tuberosities,  trochanters,  condyles  of  knees,  elbows,  and  the  heels.  First 
the  skin  reddens,  then  an  abrasion  may  form,  then  a  slough  ;  in  bad  cases 
even  spinal  canal  may  be  opened.  Causes. — Predisposing  are  debility, 
continued  fevers,  especially  typhoid,  paralysis,  old  age  ;  exciting  causes  are 
continued  pressure,  in-itation  of  faeces  and  urine,  the  under  sheet  and  night- 
shirt not  being  kept  smooth  by  the  nurse,  etc.  Prognosis. — Depends  chiefly 
upon  whether  the  cause  can  be  removed  or  not.  Treatment.— 'PreYentive 
measures  are  good  nursing,  dry,  smooth  draw-sheets,  water-beds  or  cush- 
ions, frequent  change  of  position.  The  buttocks,  etc.,  should  be  rubbed 
twice  a  day  for  five  minutes  with  camphorated  spirit,  or  with  a  mixture 
of  olive  oil  and  brandy  (equal  parts)  ;  or  bathe  the  part  with  hydrarg, 
perchlor.  in  sp.  vin.  rect.  (gr.  ij.- f  j.) ;  prominences  should  be  covered 
with  amadou  plaster ;  when  an  abrasion  forms,  apply  collodion  and  try  to 
take  off  the  pressure  ;  when  a  slough  is  forming,  use  a  thick  poultice  ; 
when  slough  separates,  use  stimulants,  e.g.,  resin  ointment,  balsam  of  Peru 
on  cotton-wool.     Prone  position  sometimes  necessarj'. 

Bees,  Stings  of. — Treatment. — Rubbing  with  olive-oil,  strong  liquor 
ammonife,  indigo,  eau  de  Cologne,  vinegar,  flour,  etc. ;  remove  the  sting  if 
it  can  be  found  ;  ice. 

Biceps  Humeri,  Contraction  of. — Treatment. — If  the  arm  can  be  ex- 
tended under  anaesthetics,  keep  it  so  for  some  time  on  a  splint ;  otherwise, 
tenotomy  may  be  required ;  but  manipulation,  patiently  practised,  will  often 
succeed. 

Biceps  Humeri,  Division  of  Tendon  of. — Insert  knife  on  inner 
side,  pass  it  beneath  the  tendon,  and  cut  outward  and  toward  the  skin ; 
press  brachial  artery  away  during  operation. 

Biceps  Femoris. — In  dividing  this,  pass  tenotome  in  parallel  to,  and 
keep  it  close  to  the  tendon. 

Bites  of  Poisonous  Snakes. — Symptoms. — Local,  are  rapid  swelling, 
redness,  lividity,  phlyctenuLe  filled  with  sanious  fluid ;  swelling  spreads, 
whole  body  assumes  a  jaundiced  hue  ;  resemblance  to  ordinary  phlegmo- 
nous erysipelas  ;  but  "  the  first  symptom,  in  nearly  all  cases,  appears  to  be 
a  general  shock  to  the  nervous  system  " — faintness,  tremor,  great  depres- 
sion, sometimes  stupor,  loss  of  sight,  vomiting,  trismus,  and  general  in- 

'  It  has  been  found  that  it  causes  the  lips  of  the  wound  to  swell  greatly,  and  some- 
times, therefore,  to  prevent  escape  of  discharge. — London  Medical  Record. 


28  BLADDER. 

sensibiKty ;  great  local  pain.  Pathology. — First  effect  is  a  shock  to  the 
nervous  system  ;  second  is  a  diffuse  cellulitis,  spreading  £rom  the  wound. 
It  appears  that  virulent  snake-poison  may  be  aj)plied  to  slight  abrasions, 
to  denuded  muscle,  cartilage,  periosteum,  to  mucous  membrane,  and  even 
to  the  medullary  cavity  of  bones,  with  no  more  effect  than  local  irritation, 
though  the  same  poison  inoculated  into  the  subcutaneous  cellular  tissue 
would  be  rapidly  fatal.  Prognosis, — Depends  on  relative  size  of  snake  and 
victim,  on  situation  of  wound  (worst  when  on  faqe  or  trunk),  and,  of 
course,  on  kind  of  snake. — See  G.  Busk,  in  "Holmes's  System."  Treatment. 
— Ligature  above  j)art  bitten ;  sucking  wound  ;  caustics,  actual  cautei-y  ; 
excision ;  injection  of  wound  with  ammonia  or  carbolic  acid  ;  injection  of 
ammonia  into  the  veins  (HaKord)  ;  Liq.  ammon.  fori,  Tri,x.,  ad  aquse  fort., 
TUxx.,  to  be  injected  into  a  large  vein  near  the  wound  ;  rubbing  with  olive- 
oil.  The  strength  must  be  kept  up  with  milk,  eggs,  wine,  soups,  etc.  ;  the 
spirits  must  be  cheered. 

Bites  of  Rabid  Animals. — See  Hydrophobia. 

Bladder,  Atony  of,  arises  from  muscular  weakness  of  old  age,  or  after 
fevers,  or  paralysis,  or  from  continued  obstruction  by  enlarged  prostate  or 
organic  strictui-e.  It  must  not  be  confounded  with  actual  paralysis. 
Symptoms. — Retention,  or  else  incontinence  of  urine,  caused  by  the  over- 
flow of  the  bladder.  Treatment. — Catheterism  twice  a  day  ;  cold  douche 
and  flections  to  lumbar  spine,  and  injections  of  cold  water.  Electricity. 
Sometimes  strychnine  when  a  spinal  affection  seems  to  be  the  cause.  Prog- 
nosis.— Depends  upon  curability  of  the  cause  and  upon  duration  of  the 
disease. 

Bladder,  Cancer  of. — Epithelioma  is  very  rare,  and  slow  in  its  progress. 
Scirrhus  is  most  rare,  except  as  an  extension  from  neighboring  organs. 
Encephaloid  is  more  common.  Symptoms. — Frequent  and  difficult  mictu- 
rition ;  pain  in  neck  of  bladder,  often  extending  to  loins  and  hips  as  well 
as  perinseum  ;  hemorrhage  usually  sudden  and  copious  ;  frequent  and 
continuous  oozings  are  more  characteristic  of  villous  growth  (Thompson)  ; 
enlargement  of  pelvic  and  lumbar  glands  ;  sometimes  cancer-ceUs  are  found 
in  urine  ;  growth  may  be  felt  j)er  rectum  or  by  catheter  ;  cachexy.  Prog- 
nosis.— Encephaloid  cases  last,  on  an  average,  twelve  months  ;  Brodie  has 
known  a  duration  of  seven  or  eight  years.  Treatment. — Attend  to  general 
health,  state  of  bowels,  appetite,  etc.  Use  anodynes,  especially  subcutane-' 
ous  morphia  injections,  with  no  niggard  hand ;  morphia  suppositories  ; 
alcoholic  stimulants.  For  the  hemorrhage,  cold,  rest,  and  injections,  silver 
nitrate,  gr.  ss.  to  3  j.,  iron,  and  other  local  astringents.  Recumbent  pos- 
ture in  some  cases.  Some  tumors  in  the  female  bladder  are  accessible  for 
operation. 

Bladder,  Catarrh  of.^ — Chronic  inflammation  v\dth  mucopurulent  secre- 
iion.  Causes. — Generally  either  stricture,  calculus,  or  enlarged  prostate ; 
often  paralysis;  atony,  ixlceration,  tumors,  cancer;  a  sequel  of  acute  cys- 


^LADDER.  29 

titis ;  may  arise  from  disease  of  neighboring  parts,  anus,  rectum,  vagina, 
and  uterus;  gout,  gonorrhoea,  foreign  bodies,  and,  in  fact,  any  irritant 
which  can  aft'ect  the  bladder.  Symj^toms, — Frequent  micturition  ;  urine 
ammoniacal,  fetid,  mixed  with  stringy  mucus,  deposits  phosj)hates  ;  the 
general  health  gradually  gives  way  ;  pain,  generally  dtdl  and  radiating 
along  perinajum,  anus,  urethra,  etc.  Pathology. — The  mucous  membrane 
is  thickened  and  congested,  and  the  subjacent  muscular  tissue  hypertro- 
phied.  Prognosis. — Recovery  may  take  place  in  i-ecent  cases,  but  old  cases 
generally  die  eventually,  worn  out,  or  else  in  a  typhoid  state.  Treatment. 
— 1.  Local :  wash  out  bladder  with  warm  water,  or  solutions  of  acetate  of 
lead  (J-  gr.  to  1  oz.),  argent,  nitrat.  (^  gr.  to  1  oz.),  nitric  acid  (Tr[|^  to  3  j.)  ; 
the  strength  may  be  gradually  inci-eased.  P.  P.  White,  of  Dublin,  uses 
4  gr.  borax  to  8  oz.  of  "very  hot  water."  "When  the  urine  is  fetid,  car- 
bohc  acid  (tT[j.  to  3  iv.).  Manij)ulate  very  gently,  and  inject  only  2  or  3  oz, 
at  a  time.  Counter-irritation  ;  croton-oil  or  iodine  to  pubes,  linseed  and 
mustard  poultices  to  pubes.  2.  Internal  remedies :  anodynes  by  mouth 
and  rectum.  Aperients.  Buchu,  uva  ursi,  pareira  brava,  triticum  repens, 
iron.  Dr.  Gross  strongly  recommends  copaiba  and  cubebs  when  the  se- 
cretion is  excessive.  Demulcents  :  decoctions  of  marsh-mallow,  linseed, 
Irish  moss,  elm-bark,  or  barley.  The  urine  should  be  made  neutral,  if  acid. 
Diet  is  very  important :  light,  nutritious,  farinaceous  ;  milk  and  fish.  Rest 
horizontally  ;  warm  clothing  ;  warm  climates.  In  severe  cases  the  litho- 
tomy incision  has  been  made  by  Gross,  Wheelhouse,  Teevan,  and  others. 

Bladdee,  Dilatation  of,  without  hypertrophy,  sometimes  exists. 

Bladder,  Extroversion  of. — A  congenital  malformation,  in  which  the 
anterior  wall  of  the  bladder  and  the  adjacent  jDart  of  the  abdominal  wall 
are  absent.  More  common  in  males  than  in  females.  Symptoms. — The 
red  mucous  membrane  of  the  posterior  wall  of  the  bladder  presents  in  the 
pubic  region  as  a  flattened  tumor,  on  which  the  orifices  of  the  ureters  may 
be  found  ;  umbilicus  absent ;  epispadias  ;  urine  always  dribbling  ;  conse- 
quent excoriations  and  urinous  odor  ;  impotence  in  the  male.  Treatment. 
— Zinc  ointment  for  excoriations  ;  urinals  carefully  fitted  to  the  case.  Rad- 
ical cure  by  operations  of  Ayres,  Wood,  or  Holmes.  Skin-flaps  are  turned 
down  from  the  neighboring  parts — groins,  scrotum,  etc. — and  united  so 
that  one  surface  of  skin  turns  toward  bladder,  the  other  outward.  T. 
Smith's  operation — ureters  into  rectum. 

Bladder,  Foreign  Bodies  t^.— Treatment. — Urethral  forceps,  litho trite, 
operation  as  for  median  lithotomy. 

Bladder,  Hypertrophy  of,  arises  from  obstruction  to  the  passage  of 
urine,  and  fi-om  continued  irritation.  Commonly  coexists  with  catarrh. 
Its  existence  can  be  inferred  from  that  of  its  causes.  Treat  the  catarrh 
and  remove  the  causes. 

Bladder,  Acute  Inflammation  of,  usuiilly  affects  trigone.  Causes. — 
Predisposing  are  male  sex,  adult  age,  cold  weather  and  season,  intemperate 


30  BLADDER. 

habits,  urinary  obstruction.  Common  exciting  causes  are  wounds,  e.g., 
lithotomy ;  calculi,  intemperance,  stricture,  gonorrhoea,  injury  during 
parturition,  protracted  retention.  Other  causes  are  blows  on  perinseum 
or  h}Tpogastrium,  stimulant  diuretics,  e.g.,  cantharides  ;  blisters,  catheter- 
ism,  lithotrity.  Si/mj^toms. — Pain  locally,  affecting  perinteum,  pubes, 
groins,  sacrum,  thighs  ;  extreme  irritability  of  bladder  ;  urine  voided  spas- 
modically as  soon  as  it  enters  bladder.  In  severe  cases,  such  as  those 
which  may  foUow  lithotomy,  there  are  rigors,  often  delirium,  extreme  local 
tenderness,  and  great  danger.  In  milder  cases,  such  as  often  result  from 
gonorrhoea,  the  symptoms  are  chiefly  local.  Urine  deposits  mucus  and 
pus  ;  in  severe  cases  it  is  bloody.  Pathology. — Usually  commences  at,  and 
is  often  confined  to  neck  of  bladder ;  mainly  affects  mucous  membrane ; 
this  is  thickened  and  congested  ;  in  protracted  cases  it  gets  dark  in  color. 
Occasionally  lymph  is  exuded  so  as  to  form  false  membrane.  Prognosis.— 
The  mild  form  yields  to  treatment.  The  virulent  form,  especially  in  shat- 
tered constitutions,  is  often  fatal,  death  being  sometimes  preceded  by 
gangrene.  Treatment. — Cathartics:  castor-oil,  black  draught,  or  calomel; 
diaphoretics ;  demulcent  drinks,  flavored  with  a  Httle  lemon-juice  ;  all 
drinks  to  be  tepid  ;  opiate  suppositories  and  enemata  ;  colchicum  in  gouty 
cases.  Hot  baths ;  liaseed  and  mustard  poultices  to  the  abdomen  and 
perinseum  ;  fomentations  ;  leeches  (five,  ten,  or  more)  to  the  perinseum 
and  margin  of  anus.  Cupping  the  loins  when  there  is  pain  in  that  region. 
Retention  should  be  watched  for  and  may  reqxiire  catheterism.  Painting 
hj'pogastrium  and  perinseum  with  T.  iodi. 

Bladder,  Inversion  of. — Four  cases  have  been  recorded.  Occurs  in 
female  children  only. 

Bladder,  Irritability  of  the,  always  a  symptom  only,  though  its  impor- 
tance has  given  it  the  rank  of  a  disease.  Causes. — 1,  Disease  of  the  urinary 
apparatus :  vesical  catarrh,  stricture,  prostatic  disease,  foreign  body,  tu- 
mor or  calculus  in  bladder,  disease  of  kidney  or  ureter,  gonorrhoea ;  2, 
state  of  urine,  most  common  in  elderly  males  ;  3,  diuretics,  cantharides  ; 
4,  venereal  excesses,  onanism,  a  long  and  narrow  prepuce  ;  5,  indigestion, 
ascarides,  hemorrhoids,  fistulse,  prolapsus  ani,  pruritus  ani ;  6,  nervous 
disorders,  hysteria,  depressing  emotions,  excessive  mental  exertion ;  7, 
debility  from  many  causes  ;  8,  exposure  to  cold  ;  9,  ovarian  and  uterine 
diseases.  Symptoms. — Frequent  micturition,  but  the  total  amount  of  urine 
passed  not  excessive.  Prognosis. — Good,  when  the  cause  can  be  removed. 
The  disease  is  intractable  in  weak,  scrofulous  subjects.  Treatment. — Re- 
move the  cause,  if  possible  ;  any  way,  treat  the  cause.  Ext.  belladonnse,  gr. 
one-sixth  per  diem  ;  coi^aiba ;  tinct.  cantharidis ;  buchu  ;  pareira  brava. 
Farinaceous  diet. 

Bladder,  Neuralgia  of. — Very  rare.  Sometimes  reflex,  and  depending 
on  conditions  of  the  liver,  kidney,  nerve  centres,  etc. 

Bladder,  Paralysis  of. — A  name  applied  to  loss  of  power  of  the  bladder, 


BLADDER.  31 

from  nervous  affections.  Weakness  from  injury  or  disease  of  its  muscular 
walls  is  called  atony  (whicti  see).  Causes. — Injuries  or  diseases  of  the 
spinal  cord  and  brain  ;  reflex  paralysis  from  operations,  especially  those  for 
hemorrhoids  ;  shock  ;  debilitating  diseases,  especially  continued  fevers ; 
sexual  excesses,  especially  in  old  men  ;  mechanical  injury,  e.g.,  in  protracted 
parturition  ;  over-distention  ;  severe  inflammation  ;  hysteria.  Symptoms. — 
Firstly,  retention,  and  then  incontinence  also.  Paraplegia  often  present. 
The  distended  bladder  forms  an  abdominal  tumor.  Prognosis. — Depends 
chiefly  on  cause.  Sometimes  fatal,  even  when  promptly  reheved.  Treat- 
ment.— Pass  a  full-sized  catheter  ;  only  partially  empty  bladder  at  first,  if 
the  distention  be  great ;  regular  catheterism  twice  a  day  ;  cathartics ;  tonics  ; 
strychnine  ;  cantharides  ;  fron  ;  quinine  ;  arsenic.  Electricity.  Counter- 
frritation  :  cold  douche.  If  possible,  avoid  catheterism  in  hysterical  cases  ; 
try  ordinary  remedies  for  hysteria. 

Bladder,  Pdnctuke  of. — 1,  Supra-pubic  :  incise  skin  for  half  an  inch  in 
middle  line,  just  above  pubes  ;  then  plunge  in  curved  trochar  downward 
and  backward  ;  leave  a  soft  catheter  in  the  wound.  2.  Per  rectum  :  guide 
a  curved  trochar  on  the  left  index  finger  in  the  rectum,  till  the  point  can  be 
placed  against  the  bladder,  in  the  middle  hne  just  behind  the  prostate. 
During  this  first  step,  keep  the  trochar  quite  sheathed  ;  then  project  the 
point,  and  plunge  the  instrument  into  the  bladder  ;  leave  in  a  soft  catheter. 

Bladder,  Rupture  of. — The  bladder  is  generally  full  at  the  time,  and 
the  patient  often  intoxicated.  The  usual  causes  are  the  passage  of  a  heavy 
wagon  over  the  abdomen,  a  fall  or  blow  on  the  hypogastrium,  a  wound,  or 
extreme  retention  of  urine.  Symptoms. — Sudden  and  violent  pain  in  the 
pelvis  or  hypogastrium  ;  great  desire  to  urinate,  but  no  urine  passes  ;  the 
catheter  readily  enters  the  bladder,  but  draws  off  only  a  small  quantity  of 
luine,  which  may  be  bloody.  Collapse,  then  peritonitis.  Prognosis. — 
Almost  always  fatal,  except  where  there  is  an  open  wound,  with  the 
peritoneum  uninjured.  Treatment. — Use  a  catheter  open  at  the  extreme 
tip,  to  keep  the  viscus  empty  ;  do  not  pass  it  far  into  the  bladder ;  use  the 
proper  remedies  for  peritonitis,  especially  opium  and  warm  applications, 
but  avoid  depletory  measures.  If  you  feel  sure  of  your  diagnosis,  it  is 
justifiable  to  open  the  abdomen  antiseptically,  wash  it  out,  and  sew  up  a 
rent  in  the  bladder. 

Bladder,  Stammering  of,  or,  rather,  of  urinary  organs. — A  condition  in 
which,  without  any  more  visible  oi'ganic  disease  than  exists  in  stammering 
of  the  vocal  organs,  the  sufferer  cannot  micturate  freely  at  will.  The  stam- 
mering is  usually  aggravated  by  anything  which  directs  the  patient's  atten- 
tion to  the  act  of  micturition,  or  which  makes  him  "nervous,"  or  by 
temporary  disorder  of  digestive  or  urinary  organs.  Treatment. — Strengthen 
general  health,  attend  to  digestion  and  state  of  urine.  Teach  patient  to 
pass  a  catheter  for  himself,  so  that  he  may  be  free  fr-om  fear  of  retention. 
(Paget's  Clin.  Led.)      ■ 


32  BOILS. 

• 

Bladder,  Tubercle  of,  seldom,  if  ever,  occurs  except  with  tubercle  of 
other  urinaiy  organs.  Symptoms. — Those  of  ulceration  in  a  tuberculous 
patient.     Treatment. — That  of  tuberculosis  :  anodynes  ;  rest. 

Bladder,  Tumors  of,  ai-e  :  1,  fibrous  ;  2,  villous  ;  or  3,  cancerous  and  not 
villous.  The  first  may  cause  no  symptoms,  or,  if  unfortunately  situated, 
those  of  obstruction  or  initation.  The  second  causes  constant  hemorrhage, 
vrhich  is  generally  at  last  fatally  exhausting.  For  the  third,  see  Cancer  of 
THE  Bladder.  The  catheter  must  be  gently  used  where  there  is  obstruc- 
tion ;  mild  astringents  and  rest  for  hemorrhage  ;  strength  to  be  supported 
by  chalybeates,  good  diet,  etc.  In  women,  vesical  tumoi-s  may  sometimes 
be  felt  and  removed  through  the  urethra.  The  villous  growth  is  some- 
times the  cause  of  severe  pain,  and  may  or  may  not  be  cancerous.* 

Bladder,  Washing  out,  may  be  done  either  with  a  double-cuiTent 
catheter  or  with  Clover's  apparatus,  with  Bigelow's  apparatus,  or  with  a 
syphon -tube. 

Bleeding. — Venesection.  Veins  used  :  median-cephalic,  median-basilic, 
external  jugular,  saphena  veins  near  ankle,  veins  of  scrotum.  Instruments 
required  :  bleeding-tape  or  bandage,  bowl,  lancet,  pad,  sponge,  and  water. 
Apply  taj)e  to  middle  of  upper  arm,  tight  enough  to  congest  veins,  but  not 
to  affect  pulse.  Hang  arm  down  a  little  while  ;  then  choose  spot  and 
apply  thumb  just  below  it.  Pass  lancet  gently  and  obliquely  into  vein, 
and  enlarge  opening  without  deepening  incision  ;  draw  off  enough  blood. 
If  necessaiy,  make  patient  work  his  hand,  opening  and  shutting  it.  Fi- 
nally, apply  pad  over  wound  ;  fix  it  with  the  tape  ;  put  ai'm  in  sling  for  two 
days.  In  opening  external  jugular,  put  the  jDad  just  above  the  clavicle, 
and  cut  in  the  direction  of  the  fibres  of  the  sterno-mastoid.  Bathe  the 
veins  of  the  scrotum  with  warm  water  before  and  after  opening  them. 
Arteriotomy. — Cut  the  temporal  artery,  or  its  anterior  branch,  half  in  two 
transversely  ;  when  enough  blood  has  flowed,  divide  it  completely,  and 
api^ly  a  pad  and  bandage. 

Blennorrhcea=Gleet,  vide  Gonorrhoea. 

Boils. — Causes. — Debility  or  plethora  (but  these  causes  are  probably 
never  sufficient  when  uncomphcated)  ;  change  of  diet ;  excessive  persjDira- 
tion  ;  hydropathy  ;  sea-bathing  ;  air  of  dissecting-rooms ;  training  ;  spring 
and  early  summer  season  ;  diabetes  ;  diseased  meat ;  irritation  of  sexual 
organs  ;  local  irritants  of  various  kinds,  e.g.,  edge  of  a  frayed  shift-collar ; 
poultices.  Symptoms. — The  local  appearances  are  well  known.  There  is 
rarely  any  fever.  Sometimes  premonitoiy  symptoms,  such  as  feeling  of  chilli- 
ness, bad  temper,  etc.  Pathology. — In  the  first  instance,  a  boil  is  frequently 
indistinguishable  from  an  acne-spot.  Indeed,  in  a  person  suffering  from  an 
attack  of  boils,  almost  any  acne-pimple .  can  be  irritated  into  a  boil  by 


'  Papilloma  of  bladder  is  always  attached  to  trigone  between  the  two  ureters 
'  (Rindfleisch). 


BONES,    DISEASES    OF.  33 

persistent  friction,  or  by  exposure  to  some  continuous  irritant,  such  as 
the  sea-water  constantly  wetting  the  wrists  of  fishermen.  A  boil  is  a  local 
celliditis,  often  spreading  from  an  inflamed  sebaceous  follicle  ;  and  the 
reason  of  this  spreading  is,  in  most  cases,  not  the  specific  nature  of  the 
original  cause,  but  persistent  local  irritation.  As  it  is  quite  as  easy  to 
protect  from  local  irritation,  and  to  check  the  acne,  as  to  cure  the  specific 
cause  of  boils,  if  there  be  one,  I  hold  that  this  yiew  of  boils  is  of  practical 
importance.  The  "  core  "  of  a  boil  is  a  central  slough  of  cellular  tissue. 
Treatment. — Local.  Soap-plaster.  Poidtices  or  water- dressing  shoidd  be 
avoided,  as  they  bring  out  fresh  boils.  Incision  (complete)  of  very  pain- 
fiQ  ones.  Ext.  belladonna  and  glycerine  on  lint.  Blind  boils  may  be 
aborted  by  the  apphcation  of  a  strong  caustic  to  the  commencing  vesicle  ; 
strong  carbohc  acid  locally  (Eade  of  Norwich).  General  Treatment. — Reg- 
ulate the  diet.  When  any  poison  appears  to  have  been  absorbed,  use 
eHminative  treatment,  e.g.,  purgatives,  Turkish  bath  ;  moderate  exercise  ; 
light  clothing ;  arsenic  ;  yeast,  one  tablespoonful  three  times  a  day.  See 
Smith's  article  in  Holmes'  "  System,"  vol.  v.  Bathe  part  where  the  boils 
chiefly  appear,  with  water  as  hot  as  it  can  be  endured,  and,  above  all,  re- 
move every  cause  of  local  friction  or  chafing. 

Bones,  Diseases  of,  resemble  those  of  the  soft  tissues,  but  are  remark- 
able for  the  extreme  slowness  with  which  the  pathological  changes  usually 
take  place. 

Note. — The  pathology  of  the  varieties  of  inflammation  in  bone  and 
periosteum  will  be  given  collectively,  for  the  sake  of  convenience  and 
clearness. 

Bone,  Atrophy  of. — Causes. — Injury,  e.g.,  fracture  ;  chronic  inflam- 
mation ;  disuse,  e.g.,  in  the  case  of  the  bone  of  a  stump ;  old  age,  e.g., 
atrophy  of  the  lower  jaw ;  pressure,  e.g.,  that  of  a  tumor.  Pathology. — 
The  bone  becomes  not  only  smaller,  but  its  cancellous  and  medtdlary 
spaces  enlarge  ;  a  certain  amount  of  fatty  degeneration  is  frequent. 

Pathology  of  Osteal  and  Peeiosteal  Inflammations — Pathology  of 
Acute  Periostitis. — Attacks  chiefly  the  long  bones,  especially  the  femur ; 
medulla  may  be  coincidently  inflamed.  In  a  typical  case,  in  which  both 
periosteum  and  medulla  are  afiected,  the  vessels  of  each  are  highly  in- 
jected, and  the  intervascular  tissue  infiltrated  with  yotmg  corpuscles  ;  this 
stage  may  end  in  complete  resolution,  in  ossification  of  some  of  the  inflam- 
matory new-formation  ;  or,  as  in  most  cases  unfortunately,  it  may  end  in 
suppuration  ;  then  the  skin  reddens,  the  oedema  becomes  marked,  and 
neighboring  joints  swell ;  the  suppuration  separates  the  periosteum,  not 
usually  from  the  whole  shaft,  but  frequently  from  half  of  it,  though  often 
only  on  part  of  the  circumference  ;  except  in  rare  instances  in  small  chil- 
dren, necrosis  is  now  inevitable.     See  Necrosis  of  Bone. 

Pathology  of  Chronic  Periostitis. — It  is  often  accompanied  by  superficial 
inflammation  of  the  bone  itself.     The  two  layers  of  the  periosteum  (in- 


34  BONES,    DISEASES    OF. 

ternal,  fibrous,  and  external,  cellulo-vascular)  cannot  be  separated  from 
each  other,  but  are  swollen,  infiltrated  with  young  cells,  and  traversed  by 
dilated  capillaries ;  they  are  easily  separated  from  the  adjacent  bone, 
whose  sui'face  is  generally  covered  with  small  nodules  of  new  bone ;  the 
general  opinion  is  that  these  nodules  (osteophytes)  grow  from  the  perios- 
teum ;  periostitis,  with  the  formation  of  these  osteophytes  and  without 
suppuration,  is  usually  sj'philitic.  When  suppuration  occurs,  it  may  be 
without  any  destruction  of  bone,  caries,  or  necrosis ;  but  usually  the  bone 
is  rough  and  gnawed,  often  to  a  considerable  extent ;  this  occurs  especially 
in  strumous  periostitis.  Then  again,  in  other  cases  of  chronic  periostitis, 
a  soft,  fluctuating  swelling  forms,  consisting  not  of  pus,  but  of  granula- 
tions springing  from  carious  bone  ;  these  cases  are  often  also  strumous. 

Pathology  of  Caries. — Chronic  inflammation  causes  the  corpuscular  and 
vascular  elements  of  the  soft  parts  of  bones  to  increase  at  the  expense  of 
the  earthy  parts  ;  the  young  cells  seem,  as  it  were,  to  corrode  the  walls  of 
the  lacunas,  etc.,  in  which  they  lie  ;  these  corrosions,  spreading  and  unit- 
ing, may  cause  destruction  to  an  indefinite  extent ;  the  bone  thus  corroded 
is  dissolved,  and  is  either  absorbed  or  flows  away  in  the  discharges. 
Around  the  region  of  caries  is  sometimes  a  zone  of  sclerosis,  i.e.,  of  bone 
in  which  the  inflammatory  new  material  has  ossified  between  the  trabeculse 
of  the  original  bone.  The  distinctive  characters  of  strumous  caries  are 
thus  given  by  Walsham  ("  Surgical  Pathology,"  p.  16)  :  "  It  is  characterized 
by  the  tendency  of  the  inflammatory  products  to  undergo  caseous  degenera- 
tion, by  the  extensive  destniction  of  the  affected  part,  by  the  softened, 
fatty,  and  oily  condition  of  the  bone  around,  by  little  tendency  to  the  for- 
mation of  new  bone,  and  by  feeble  efforts  toward  repair." 

Pathology  of  Necrosis. — Dead  bone  is  bloodless,  and  either  white,  or 
else  darkened  by  the  action  of  air,  pus,  or  blood  ;  on  the  surface  lately  con- 
tinuous with  living  bone  it  is  rough  and  corroded  ;  but  on  the  free  sur- 
face, usually  smooth.  The  process  of  separation  of  necrosed  bone  is  as 
follows  :  granulations  form  at  the  plane  of  contact  of  Hving  and  dead  bone, 
and  these  granulations  dissolve  the  earthy  medium  still  uniting  the  dead 
to  the  living  bone,  thus  setting  the  former  free  ;  the  soft  tissues  in  con- 
tact with  dead  bone  loosen  from  it  everywhere,  and  often  a  layer  of  pus 
intervenes  ;  then  the  dead  bone  lies  in  an  abscess-cavity.  When  part  or 
whole  of  the  shaft  of  a  long  bone  necroses,  these  same  neighboring  soft 
parts,  most  especially  the  periosteum,  proceed,  as  a  rule,  to  build  a  shell 
of  new  bone,  Avithin  which  the  necrosed  bone  lies  ;  this  shell  is  perforated 
in  one  or  more  places  by  cloacae  (passages  for  the  egress  of  discharge) ; 
the  piece  of  necrosed  bone  is  called  the  sequestrum ;  it  takes  months  to 
separate  from  the  living  bone ;  it  is  eventually  either  discharged  or  ab- 
sorbed, or  removed  by  operation,  or  it  may  remain  even  for  years.  So 
long  as  it  remains,  the  new  bone  around  it  usually  grows  thicker  ;  when  it 
is  removed,  the  remaining  cavity  fills  with  granulations,  which   ossify ; 


BONES,    DISEASES    OF.  35 

gradually  the  new  bone,  by  a  process  of  external  absorption  and  internal 
growth,  gets  to  resemble  more  and  more  the  shape  and  consistence  of  the 
original  bone  whose  place  it  is  to  take.  Practically  speaking,  only  the 
smallest  sequestra  can  be  absorbed.  In  necrosis  of  flat,  and  of  short, 
spongy  bones,  there  is  small  prospect  of  thorough  reproduction  ;  in  these 
cases  necrosis  is  usually  combined  with  caries,  and  often  with  a  chronic 
constitutional  disorder.  Necrosis,  when  confined  to  the  surface  of  a  bone, 
is  called  "  superficial,"  and  when  to  the  interior  of  a  bone,  "  central ; "  in  the 
former  the  sequestrum  is  called  an  "exfoliation  ;"  central  necrosis  consti- 
tutes almost  an  independent  disease. 

Pathology  of  Central  Necrosis  is  the  result  of  inflammation  of  the 
deeper  parts  of  a  bone,  and  is  usually  accompanied  by  caries ;  it  leads  to 
a  bone-abscess,  to  a  simultaneous  periostitis  on  the  neighboring  external 
surface  of  the  bone,  and  to  a  consequent  apparent  thickening  of  the  bone. 
Note  :  though  central  necrosis  is  pretty  stire  to  lead  to  abscess,  yet  abscess 
of  bone  does  not  usually  imply  necrosis. 

Chronic  Abscess  of  Bone. — First  described  by  Brodie.  Most  usual 
seat,  head  of  tibia.  Causes. — Obscure,  sometimes  injury.  Symptoms. — 
Those  of  ostitis  and  periostitis  confined  to  a  circumscribed  locality.  An 
abscess  is  suspected  because  of  the  persistence  of  the  symptoms,  and  be- 
cause of  the  localized  and  circumscribed  tenderness.  Diagnosis  and 
treatment  require  the  same  proceeding,  viz.,  trephining  at  the  tenderest 
spot.  Generally  the  abscess  is  here  very  superficial.  The  trephine  has  in 
some  cas^  just  missed  the  cavity.  Holmes  advises  in  such  cases  to  per- 
forate the  walls  of  the  trephine-hole  in  several  directions  in  search  of  the 
pus.  Prognosis  is  excellent  when  the  trephine  j)ierces  the  abscess  ;  other- 
wise thei'e  is  danger  of  abscess  opening  into  a  neighboring  joint. 

Inflammation  of  Bone. — Three  chief  varieties,  according  to  part  mainly 
attacked,  viz.,  ostitis,  periostitis,  and  osteo-myelitis. 

1.  Ostitis. — Inflammation  may  begin  in  the  bone  proper,  without  affect- 
ing the  periosteum  or  medulla  at  first.  Causes. — Though  it  is  often  ex- 
cited by  an  injury,  there  is  usually  some  predisposing  cause — sj^hUis, 
struma,  or  simple  constitutional  debility.  Symptoms. — Deep-seated,  ach- 
ing pain,  worse  at  night,  and  other  symptoms,  all  like  those  of  periostitis. 
Pesults. — It  usually  ends  in  either  caries  or  sclerosis,  quod  vide.  Treat- 
ment.— Counter-ii'ritants,  e.g.,  iodine,  or  warmth  and  moisture  locally,  or 
cold  applications.  Treat  cause  ;  iodide  of  potassium.  Linear  osteotomy 
in  bad  cases — Erichsen.  Linear  osteotomy  is  the  longitudinal  division  of 
the  part  of  the  bone  affected,  down  to  the  medullary  canal,  by  a  Hey's 
saw.  Mild  counter-irritants,  rest,  and  elevated  position,  perhaps  gentle 
compression  and  weak  purgatives,  are  the  best  abortive  treatment  when 
the  disease  is  commencing. 

2.  Periostitis,  Chronic  or  Subacute — Causes. — Syphilis,  rheumatism,  in- 
juries ;  may  be  secondary  to  ostitis,  or  spread  from  an  inflamed  articu- 


36  BONES,    DISEASES    OF. 

lation.  Symptoms. — Swelling,  aching  pain,  worse  at  night ;  heat ;  skin 
usually  not  reddened  ;  swelUng  mostly  in  the  form  of  anode.  Prognosis. — 
Usually  ends  in  resolution  ;  often  causes  thickening  of  the  bone,  growth  of 
osteophytes ;  rarely  ends  in  suppuration.  Treatment. — See  Ostitis.  Also 
an  incision,  subcutaneous  or  otherwise,  to  relieve  a  bad  case. 

Periostitis,  Diffuse — Causes. — Age,  usually  about  puberty;  sex,  mostly 
in  boys  ;  generally  follows  injury  ;  strumous.  The  effusion  strips  the  peri- 
osteum from  the  bone,  and  almost  always  causes  necrosis,  sometimes  of  an 
entire  shaft  of  a  long  bone.  Symptoms. — Femur  or  tibia  usually  affected  ; 
swelling,  heat  and  pain,  easily  confounded  with  cellulitis  or  acute  rheuma- 
tism, but  it  does  not  spread  over  the  joints  above  and  below  the  bone  ; 
both  local  and  constitutional  symptoms  very  severe  ;  suppuration ;  then 
rigors,  glistening  skin,  fluctuation,  etc.  For  further  course,  etc.,  see  Necro- 
sis. Prognosis. — Highly  dangerous  ;  death  may  occur  before  suppuration, 
or  may  result  from  exhaustion  or  pyaemia  afterward.  Diagnosis. — From 
acute  rheumatism  or  cellulitis  ;  care  only  required  ;  no  rheumatic  affection 
of  heart,  or  any  separate  joint ;  fever  different,  etc.  Treatment. — Rest,  ele- 
vated position  ;  local  applications,  warm  fomentations  ;  free  incision  when 
abscess  has  fairly  formed  ;  incisions  to  remove  tension  at  an  earlier  period 
usual  Such  early  incisions  predispose  to  pyaemia  (Billroth).  Such  inci- 
sions can  be  made  antiseptically.      Vide  also  Necrosis. 

3.  Osteo-myelitis,  or  inflammation  of  the  medulla  of  a  bone,  is  extremely 
rare,  except  as  the  result  of  direct  injurj',  e.g.,  from  compound  fracture  or 
after  amputation  through  a  bone.  Inflammation  of  a  bone  may  be  judged 
to  begin  in  the  medulla  if  the  swelling  does  not  appear  till  some  days  after 
the  severe  local  pain  ;  there  is  always  violent  fever  ;  the  periosteum  sepa- 
rates from  the  diseased  bone  without  being  pushed  off  by  suppuration  ;  the 
prognosis  and  treatment  resemble  those  of  diffuse  periostitis,  only  the  for- 
mer disease  is  even  more  serious  ;  authorities  are  divided  as  to  whether  a 
limb,  kno\sTi  to  be  affected  with  acute  osteo-myelitis,  should  be  amputated 
or  not ;  a  Hmited  osteo-myelitis,  after  amputation  and  leading  to  a  slight 
necrosis,  is  frequent,  and  not  necessarily  serious. 

Necrosis. — Causes. — The  same  as  those  of  jDeriostitis,  ostitis,  and  osteo- 
myehtis.  Necrosis  of  the  jaw  occurs,  less  frequently  now  than  formerly, 
among  workers  in  phosphorus  ;  and  it  is  said  that  the  phosphorus  fumes 
attack  only  those  with  unsound  teeth.  For  immediate  causes,  see  the  sec- 
tion on  Pathology  of  Bone  Diseases  {supra).  Symptoms  and  Diagnosis. — 
Necrosis  may  be  fairly  presumed  to  have  occurred  when  (1)  inflammation 
of  a  long  bone  or  its  periosteum  has  been  acute  or  prolonged,  while  (2) 
extensive  hard  thickening  has  taken  place,  indicating  the  formation  of  new 
bone,  and  (3)  the  pus  from  any  sinus  existing  is  thick  and  yellow.  In 
caries,  on  the  other  hand,  the  spongy  bones  are  the  usual  seat,  the  forma- 
tion of  new  bone  is  usually  slight,  the  pus  thin  and  serous  ;  but  the  probe 
is  reqtiired  to  settle  the  diagnosis.     If  gently  used  it  causes  little  or  no  pain 


BONES,    DISEASES    OF. 


n 


in  necrosis,  usually  much  pain  in  caries  ;  the  sequestrum  in  necrosis  feels 
smooth  and  hard  ;  carious  bone  is  rotten  ;  but  it  is  to  be  remembered  that 
the  probe  may  fail  to  reach  the  sequestrum,  and  that  in  a  few  cases  enoi- 
mous  thickening  exists  with  caries  only.  The  probe  should  be  pressed 
firmly  against  the  sequestrum,  to  feel  if  it  is  movable  and  ready  for  "  se- 
questrotomy."  Necrosis  is  sometimes  foimd  to  have  occurred  without  any 
history  of  precedent  inflammation.  This  is  called  "  Quiet  Necrosis."  Vide 
Paget's  "Clinical  Lectures,"  and  Morrant  Baker,  in  "St.  Bartholomew's 
Hospital  Reports,"  vol.  xiii.  Prognosis  depends  on  the  acuteness  of  the  in- 
flammation, and  on  the  extent  of  bone  involved.  Acute  necrosis  of  the  whole 
shaft  of  a  long  bone  is  excessively  dangerous.  Pytemia  sometimes  follows 
the  opening  of  the  abscess.  Treatment. — Treat  the  cause,  e.g.,  struma  ;  be- 
fore suppuration,  try  to  cause  resolution  by  counter-irritants,  cold,  etc;; 
when  abscess  has  fairly  formed,  open  it ;  some  recommend  incisions  before 
then,  merely  to  reheve  the  tension  of  the  periosteum.  Billroth  condemns 
this  plan,  saying  that  it  predisposes  to  pyaemia.  When  necrosis  has  actually 
taken  place,  you  must  wait  till  the  sequestrum  has  loosened  and  then  re- 
move it,  treating  the  general  health  in  the  meantime.  Unless  the  seques- 
trum can  be  felt  loose,  a  very  considerable  time,  even  many  months,  had  bet- 
ter be  allowed  before  attempting  to  remove  it  by  operation.  Operation  for 
Necrosis. — Tourniquet,  or  (much  better)  Esmarch's  bandage  ;  sponges,  etc., 
scalpel,  Hey's  saw,  cutting-phers,  necrosis-forceps,  gouges,  chisels,  hammer, 
probe,  oiled  lint,  bandages,  and  minor  instruments.  Incise  the  soft  parts ; 
it  is  often  advisable  to  unite  two  sinuses  by  the  incision.  Cut  a  suflicient, 
but  no  larger,  opening  in  the  sheath  of  new  bone  ;  divide  the  sequestrum  if 
it  cannot  easily  be  removed  whole  ;  plug  the  cavity  with  oiled  lint.  When 
the  whole  shaft  of  a  long  bone  has  necrosed,  it  had  better  be  removed  as 
soon  as  the  acute  symptoms  have  passed  away,  unless  the  epiphyseal  car- 
tilages have  been  involved  in  the  inflammation.  It  may  be  desirable  to 
divide  it  in  the  middle  by  a  chain-saw.  A  new  shaft  may  be  expected  to 
form,  unless  the  epiphyseal  cartilages  have  been  destroyed  ;  in  this  case  a 
new  shaft  can  only  be  expected  when  the  sequestrum  is  left  for  a  long  time 
in  sitiX.  If  the  necrosis  be  extensive,  and  for  some  reasons  cannot  be  re- 
moved, while  the  patient's  health  is  giving  way,  amputation  must  be  done. 

Hypeetkophy  of  Bone  is  commonly  the  result  of  inflammation,  which 
may  or  may  not  be  specific.  The  cause  should  be  treated.  The  disease 
may  follow  a  blow. 

Bone,  Injueies  of. — Blows  are  liable  to  cause  atrophy  in  the  old,  and 
strumous  disease  in  the  young  and  weakly ;  they  are  sometimes  followed 
by  hypertrophy.     See  Fractttres,  etc. 

MoLUTiEs  OssiuM. — A  discase  allied  to  fatty  degeneration  of  bone. 
Causes. — Mostly  attacks  females  ;  age,  middle  Ufe  or  later  ;  pregnancy. 
Symptoms. — At  first,  rheumatic  pains,  then  various  bones  soften  and 
benii,  and  afterward  fracture.     The  general  health  is  only  injured  by  the 


38  BONES,    DISEASES    OF. 

physical  effects  of  the  resulting  fractures  and  deformities.  The  chest  and 
spine  being  deformed,  the  thoracic  and  abdominal  viscera  may  be  com- 
pressed, and  a  distorted  pelvis  impedes  dehvery.  Large  quantities  of 
phosphates  in  the  urine.  Diagnosis. — From  rheumatism,  syphihs,  and 
cancer  ;  a  bone  fractui-ed  through  the  weakening  effect  of  cancerous 
deposit  gives  way  suddenly  without  bending  previously.  Prognosis. — 
Almost  always  fatal  sooner  or  later,  through  weakening  the  power  of  the 
constitution  to  resist  intercurrent  disorders  ;  rarely  fatal  through  its  own 
cachexia ;  cases  of  recovery  are  excessively  rare.  Treatment. — Tonics, 
cod-liver  oil,  phosphates,  attention  to  digestive  fionctions  ;  special  gymnas- 
tics for  the  deformities. 

Osteitis  Defokmans. — A  very  rare  disease,  lately  described  by  Sir 
James  Paget  in  the  "  Medico-Chirurgical  Society's  Transactions."  Chief 
Characteristics. — General  enlargement  of  the  bones,  with  sufficient  soften- 
ing to  permit  sHght  loss  of  height  (several  inches)  through  arching  of  the 
long  bones  of  the  lower  extremities  and  bending  forward  of  the  head  on 
the  breast ;  ribs  also  thick  and  immovable  ;  skull  thickened ;  cranial 
sutures  obliterated  ;  compact  substance  greatly  increased.  According  to 
Butlin,  the  microscopic  changes  indicate  that  the  disease  is  an  inflamma- 
tion rather  than  a  new-growth.  In  this  view  Paget  concurs,  hence  the 
name  "osteitis."  But  the  frequent  coincidence  of  sarcoma  and  carcinoma 
with  this  affection  is  most  remarkable.  Little  or  no  pain  usually,  only 
clumsiness.  Disease  lasts  for  years,  and  death  has  often  occurred  from 
the  intercurrence  of  the  above-mentioned  malignant  tumors.  The  usual 
remedies  for  other  forms  of  osteitis  apj^ear  to  be  of  no  avail.  The  large 
doses  of  pot.  iod.  and  of  arsenic,  which  have  given  Esmarch  and  Billroth 
encouraging  results  in  the  treatment  of  new-growths,  have  not,  to  my 
knowledge,  been  tried  in  this  very  rare  disease. 

Osteo-An-s^urism,  or  Pulsating  Tumor  of  Bone. — Almost  always  malig- 
nant ;  usually  occurs  in  cancellous  ends  of  long  bones,  in  skull,  and  pelvis. 
Symptoms. — A  tumor,  "  oval,  uniform,  and  elastic  to  the  touch,  growing 
slowly  ; "  pulsation  and  a  bruit  (the  latter  sometimes,  but  rarely,  absent). 
Tumor  may  be  partially  emptied  by  pressure,  and  then  the  bony  margin 
of  the  cavity  in  which  it  lies  may  be  felt.  Crackling  shell  of  bone  some- 
times felt  over  it.  Diagnosis. — 1.  The  diagnosis  of  innocent  from  malig- 
nant pulsating  tumor  :  in  the  latter  case  there  may  be  evidence  of  ma- 
lignant disease  elsewhere  ;  the  tumors  may  be  multiple  ;  the  growth  is 
probably  more  rapid  and  the  tumor  painful.  2.  From  ordinary  aneurism  : 
by  considering  the  situation  and  the  characters  mentioned  above.  Progno- 
sis.— Depends  upon  whether  tumor  is  malignant  or  not.  Treatment. — For 
innocent  cases  try  pressure  on,  or  ligature  of,  the  main  artery  ;  Esmarch's 
bandage  might  be  tried  ;  innocent  tumors  have  also  been  gouged  out.  All 
other  cases  require  amputation. 

Sanguineous  Tumors  of  Bone. —  Vide  Cystic  Tumors. 


BONES,    DISEASES    OF.  39 

Scrofulous  Disease  OP  Bone. — Causes. —  Vide  Scrofula.  Often  follows 
injiiry.  Symptoms. — Swelling,  usually  of  an  indolent  and  chronic  char- 
acter; superjacent  skin  commonly  pale,  hence  the  term  "white  swelling." 
Other  symptoms  of  scrofula  :  in  a  large  proportion  of  cases  some  internal 
organ  is  the  seat  of  tuberculous  or  cheesy  deposit.  As  the  disease  advances, 
there  are  symptoms  of  caries  and  abscess,  the  latter  often  appearing  far 
away  from  the  diseased  bone.  Most  of  the  sufferers  are  children.  The 
mischief  often  spreads  to  neighboring  joints,  and  the  suppuration  tends  to 
spread  far  and  wide  along  intermuscular  spaces,  etc.,  before  the  abscess 
bursts.  Diagnosis  rests  on  the  local  symptoms  above  given,  and  on  the 
presence  or  absence  of  other  signs  of  the  scroftilous  diathesis.  Prognosis. 
— Local  recovery  may  usually  be  expected  (in  about  two  years,  according 
to  Stanley)  if  the  general  health  holds  out,  but  relapse  is  very  common 
both  in  the  original  seat  of  the  disease  and  elsewhere.  Treatment. — Gen- 
eral treatment  of  scrofula.  Locally :  complete  rest ;  counter-irritation  by 
painting  with  iodine,  etc.,  tiU  abscess  fairly  forms,  and  even  afterward 
(Furneaux  Jordan).  There  are  special  apparatus  to  give  rest  to  special 
parts  of  the  body  :  e.g.,  for  morbus  coxce  and  for  Pott's  curvature,  quod 
vide.     Remove  the  diseased  bone  by  operation  in  suitable  cases. 

SYPHOiiTic  Disease  of  Bone. — Usually,  if  not  always,  begins  in  the  adja- 
cent soft  parts.  Symptoms. — The  first  are  usually  pains  like  those  of  rheu- 
matism, and  worse  at  night.  They  are  called  "osteoscopic."  Then  nodes 
are  found.  They  are  circumscribed,  round  or  oval  swellings,  occurring 
chiefly  on  such  bones  as  are  subcutaneous,  but  sometimes  elsewhere,  e.g., 
upon  the  inner  surface  of  the  skull.  The  primary  affection  is  in  the  peri- 
osteum. Small  tendency  to  suppuration.  Production  of  new  bone.  Caries 
and  necrosis  caused  by  more  acute  syphHitic  periostitis.  Three  forms  of 
syphilitic  ulceration  of  bone,  viz.,  the  annular,  the  tuberculated,  and  the 
reticulated.  Dry  caries  (caries  sicca)  is  frequently  syphilitic.  Syphilis, 
by  destroying  the  bones,  causes  peculiar  deformities  in  some  parts,  e.g., 
flat  nose,  destruction  of  palate,  etc.  Syphilitic  ozoena.  Epilepsy  from 
pressure  of  intra-cranial  nodes.  Diagnosis. — Ulcerations  have  character- 
istic syphiHtic  shape,  appearance,  and  history.  Syphilitic  nodes  are  known 
by  their  position,  hardness,  indolence,  and  liability  to  nocturnal  pains. 
Prognosis. — Good  except  in  tertiary  syphilitic  ulceration  ;  bad  cases  of  this 
are  sometimes  quite  incurable.     Treatment. —  Vide  Syphilis. 

Bone,  Malignant  Disease  op. — :True  carcinoma  of  bone  is  said  to  be 
always  secondary,  never  primary.  Most  so-called  "  cancers  of  bone  "  are  sar- 
comata. For  full  details  as  to  structure  of  "osteoid  cancers,"  see  Walsham 
in  "St.  Bartholomew's  Hospital  Reports,"  vol.  xv.,  and  for  full  details  as  to 
chnical  history  of  malignant  tumors  of  bone,  see  Butlin's  lectures  in  British 
Medical  Journal  for  July,  1880.  Sarcomata  of  bone  commence  either  cen- 
trally or  subperiosteally.  The  latter  are  far  more  likely  to  recur  and  to 
infect  the  system  than  the  former.     The  lower  end  of  femur  and  upper  end 


40  BONES,    DISEASES    OF. 

of  tibia  are  the  most  common  seats  of  central  sarcoma.  The  lungs  are  the 
usual  seats  of  secondary  infection.  Both  central  and  periosteal  tumors  of 
bone  frequently  become  ossified  (osteo-sarcoma,  osteo-chondroma,  etc.). 
However  much  the  shaft  of  the  bone  may  be  affected,  the  articular  cartilage 
remains  healthy.  Some  tumors  are  perfectly  encapsuled,  others  infiltrate 
every  neighboring  structure.  The  bone  may  give  way  at  the  seat  of  dis- 
ease, a  fracture  thus  resulting.  When  carcinoma  of  a  bone  does  occur,  it 
is  usually  encephaloid.  Diagnosis. —  Vide  Canceb.  Enchondroma  and 
even  cancellous  exostoses  sometimes  resemble  malignant  tumors  in  their 
rapid  growth.  But  they  may  be  recognized  by  their  hardness.  Prognosis. 
— As  above  mentioned,  central  sarcoma  is  less  likely  to  reciir  than  perios- 
teal sarcoma.  Frequently  no  recurrence  takes  place  after  thorough  removal, 
and  these  tumors  occasionally  reach  a  large  size  before  infecting  the  sys- 
tem. Treatment. — Excise,  except  when  disease  has  infiltrated  regions 
which  cannot  be  removed,  e.g.,  certain  parts  of  the  skull.  Unless  the 
tumor  is  e\ddently  circumscribed,  remove  the  whole  bone.  This  generally 
necessitates  amputation  at  the  joint  above.  But  in  cases  of  disease  of  the 
lower  end  of  the  femur,  it  is  not  usual  to  exarticulate  at  the  hip,  that  opera- 
tion being  so  dangerous.  Still,  when  the  cancer  is  soft  and  diffuse,  even 
this  risk  should  be  run. 

Tdmoes  of  Bone. — The  innocent  are  enchondroma,  exostosis,  cystic, 
fibrous,  fibro-cystic,  and  hydatids.  Vide  the  various  articles.  Tumor,  Ex- 
ostosis, Entozoa,  etc.  The  great  majority  of  innocent  tumors  of  bone  are 
either  exostoses  or  enchondromata. 

Ulceration  of  Bone. —  Vide  Caetes. 

Caeies. — Causes. — Predisposing  are  scrofula,  syphilis,  and  constitutional 
weakness,  such  as  arises  from  old  age.  Exciting  cause,  often  some  injury. 
Symptoms  are  those  of  ostitis  leading  to  the  formation  of  an  abscess. 
When  this  oj)ens,  a  probe  can  often  detect  the  softened  bone.  If  the  probe 
will  not  reach  the  disease,  the  occurrence  of  certain  deformities,  e.g.,  Pott's 
curvature,  may  offer  a  sure  sign.  Scrofulous  caries  usually  attacks  the 
vertebrae,  articular  epiphyses,  phalanges,  and  metacarpal  bones.  Syphi- 
litic ulceration  affects  mostly  the  tibia,  cranium,  sternum,  hard  palate,  and 
nasal  bones.  Diagnosis. — In  the  early  stage  the  bone  may  not  be  recog- 
nized to  be  diseased  at  all,  or  may  be  supposed  to  be  merely  rheumatic. 
Prognosis. — Ulcers  of  bone  often  cicatrize  :  bad  cases  not  very  hopeful. 
The  younger  the  patient,  and  the  less  important  the  bone,  the  better  the 
prognosis.  Danger  of  amyloid  disease,  and  fatty  degenerations  of  impor- 
tant organs  supervening.  Treatment. — Constitutional  for  the  scrofula  or 
syphilis,  etc.  Local :  rest,  elevation,  the  usual  treatment  of  inflamed  bone 
at  first,  then  that  of  chronic  abscess.  If  the  patient's  general  health  be 
tolerably  good,  and  the  locality  of  the  disease  suitable,  the  carious  bone 
may  be  removed  by  gouge,  gouge-forceps,  chisel,  or  Marshall's  osteotrite. 
Use  of  strong  or  slightly  dilute  nitric  or  sulphuric  acids.     When  a  bone  ia 


BEEAST.  41 

sufficiently  diseased,  resection  (complete  or  partial)  is  sometimes  justifi- 
able, or  amputation  may  be  required,  occasionally,  to  save  life. 

Boutonniere  Operation. — A  term  applied  to  a  proceeding  in  whicli 
a  "  button-hole  "  is  pui'posely  made  in  some  part.  It  is  done  through  the 
soft  palate,  to  facilitate  the  extraction  of  polypi,  and  into  the  urethra  from 
the  perineum,  in  order  to  expose  the  commencement  of  an  "  impermeable 
stricture." 

Breast,  Abscess  of. — Three  varieties :  1,  supra-mammary ;  2,  mam- 
mary ;  and  3,  post-mammary.  Abscess  in  the  breast  almost  always  at- 
tacks suckhng  women  in  a  feeble  state  of  health,  and  generally  soon  after 
delivery.  First  variety  is  the  most  common  in  other  people  ;  subjects  of 
third  variety  are  often  tuberculous.  Symptoms. — General  symptoms  of 
abscess.  Supra-mammary  runs  a  quick  course.  Intra-mammary  causes 
the  greatest  pain.  Post-mammary  pushes  the  whole  breast  forward :  in 
it,  too,  the  fluctuation  is,  at  first,  quite  deep,  and  eventually  several  open- 
ings often  form.  Treatment. — On  general  principles.  Deep  abscesses 
should  be  opened  as  soon  as  fluctuation  can  be  fairly  felt.  Line  of  incision 
should  radiate  from  nipple.  Attention  to  the  general  health  vrill  usually 
cure  the  fistulae  vyhich  often  remain.     Quinine. 

Breast,  Amputation  of. — Scalpel,  forceps,  artery-forceps,  sutures, 
sponges,  dressings.  Ellii^tical  incisions  parallel  with  fibres  of  pectoralis 
major  ;  lower  to  be  made  first  :  separate  gland  from  parts  beneath  before 
making  upper  incision.  Proper  support  and  pressure  required  from  dress- 
ings.    Drainage.     Mortality,  10  per  cent. 

Breast,  Atrophy  of. — Occurs  after  middle  age.  It  may  be  caused 
by  the  occurrence  of  new  growths.  Breasts  apparently  atrophied  may 
perform  their  functions  properly  when  called  upon. 

Breast,  Cancer  of. — Almost  always  scirrhus.  May  be  encephaloid  or 
colloid  ;  or  may  be  compUcated  with  blood-cysts.  Causes. — Obscure. 
Age,  middle  and  later  life,  especially  from  40  to  50  years.  Cancer  in  youth 
mostly  encephaloid.  Sex — female.  Dej^ressing  influences  (?).  Change 
of  life  (?).  Injuries.  Family  predisposition.  ^  Follows  chronic  eczema  of 
the  nipple.  Symptoms. — Fii-stly,  of  scirrhus.  A  tumor,  hard,  nodulated, 
heavy.  Implication  of  neighboring  tissues,  retraction  of  nipple.  Affection 
of  skin,  which  reddens  and  thickens,  and  afterward  ulcerates ;  severe 
pain  ;  cachexia  ;  enlarged  and  hai'dened  glands  in  axilla,  afterward  in 
neck  ;  oedema  of  the  arm  ;  occasional  direct  infection  of  the  pleura.  Con- 
stitutional infection.  Encephaloid  of  Breast  begins  as  a  soft  oval  tumor, 
usually  deeply  placed,  grows  rapidly,  may  be  mistaken  for  abscess ;  feels 
like  several  soft  tumors  together  ;  skin  ulcerates  ;  ftrngus  ;  sloughing  ; 
bleeding;  glandular  infection,  etc.  Diagnosis. —  Ft(^e  Tumors  of  Breast. 
Frognosis.^-Ahnost  always   recurs  after   removal.     Average   duration  of 

'  This  exerts  much  less  influence  than  is  commonly  believed. 


42  BREAST. 

scirrhus,  four  years  ;  longer  in  old  people.  Treatment. — Palliative  or 
operative.  1.  Palliative :  pressure  by  Ai'nott's  bags,  or  soft  compressor 
and  bandages  ;  belladonna,  atropine,  and  aconite  externally  ;  poultices  with 
belladonna.  For  ulcerated  stage,  carbolic  lotion  v^ith  oakum ;  opium  ; 
iodoform ;  ol.  eucalypt.  ;  terebene  ;  caustics  for  ulcerated  surfaces.  2. 
Operation :  prospects  doubtful  as  to  whether  it  will  lengthen  life  or  not. 
But  Morrant  Baker  found  in  eighty-four  cases,  not  operated  on,  duration 
of  life  to  be  forty-three  months,  and  in  sixty-two  cases  operated  on,  fifty- 
six  and  a  half  months.  Operation  certainly  may  be  expected  to  free  patient 
from  much  discomfort  and  distress.  When  fatal,  it  is  usually  because  of 
erysipelas  or  pyasmia.  Contra-indications  to  operation  are,  1,  considerable 
affection  of  skin  ;  2,  of  glands  in  axilla,  or  even  slight  affection  of  cervical 
glands  ;  3,  affection  of  parts  beneath  breast  ;  4,  cancer  in  both  breasts  ;  5, 
great  cachexia ;  6,  constitutional  infection ;  7,  very  chronic  course  in  old 
people.  Old  age  and  weakness  are  not  absolute  contra-indications,  nor  is 
tdceration,  ^^er  se.     For  operation,  vide  Amputation  of  Breast. 

Functional  Disorders  of  Breast, — The  milk  may  be  excessive  or  de- 
ficient, or  (3)  it  may  flow  away  (galactorrhea),  or  (4)  may  congest  the 
gland.  For  galactorrhoea,  tonics,  iron,  iodides  ;  externally,  belladonna, 
hemlock  (and  internally  too,  with  opium).  When  milk  curdles,  and  forms 
hard  lumps  in  the  gland,  use  stimidating  liniments. 

Galactocele. — A  milk-tumor,  caused  by  the  dilatation  or  by  the  rup- 
ture of  a  duct.  Always  forms  during  lactation.  At  first  fills  and  grows 
larger  each  time  the  child  sucks ;  fluctuation  ;  no  pain  ;  no  discoloration 
of  skin  ;  afterward,  fluid  parts  of  contents  tend  to  be  absorbed.  At  this 
last  stage,  the  main  element  in  diagnosis  is  often  the  history.  Treatment. 
— Incise  or  puncture  with  a  trochar  and  canula,  obliquely  from  nipple 
toward  tumor. 

Hyperzesthesia  of  Breast  and  Neuralgia  of  Breast. — Causes. — Chiefly 
lie  in  state  of  uterus,  ovary,  or  other  organs  of  generation  ;  weakness ; 
"  nervous  temperament."  Mostly  young  girls ;  sexual  depravity.  Symptoms. 
— Pain,  variable,  often  intense,  shooting  into  arm,  neck  and  back ;  super- 
ficial tenderness,  often  exquisite  ;  sometimes  redness  and  swelling  ;  swell- 
ing of  nipple.  Diagjiosis. — Rests  on  age  and  character  of  patient,  on 
variability  of  pain,  and  superficial  nature  of  the  tenderness,  and  on  negative 
signs.  Treatment. — Remove  the  cause  ;  if  necessary,  use  the  speculum, 
but  avoid  it  if  possible  ;  correct  bad  habits  ;  treat  all  disordered  func- 
tions ;  use  the  ordinary  remedies  for  restoring  the  tone  of  the  nervous 
system.  Avoid  handhng  and  examining  more  than  is  necessary.  Emp. 
belladon. 

Hypertrophy  of  Breast. — Two  forms,  viz.,  1,  firm  ;  2,  pendulous  and 
loose.  Causes. — Unknown.  Appears  soon  after  puberty.  Symptoms. — In 
form  1,  the  breast  projects,  large  and  firm ;  in  form  2,  the  organ  hangs 
dovm  relaxed,  and  may  reach  an  enormous  size.     Both  breasts  generally 


BREAST.  43 

affected.  Neuralgia  often  occurs  with  it.  Treatment. — Not  very  suc- 
cessful. Support  and  pressure.  In  extreme  cases,  amputation  may  be 
done. 

Inflammation  of  Breast. — May  occur  even  in  infancy,  but  most  cases  oc- 
cur in  suckling  women.  Causes. — Debility ;  protracted  suckHng ;  the 
irritation  of  some  disease  of  the  nipple  ;  obstruction  to  a  gland  duct ;  often 
coincident  with  defective  nipple.  Symptoms. — Lobular  induration,  per- 
haps owing  to  the  obstruction  of  a  duct :  this  is  called  a  "  lump,  knot,  or 
coring  of  the  mUk  ; "  pain  ;  tenderness  ;  redness  ;  shivering  ;  feeling  of  illness. 
The  signs  of  mere  inflammation  may  disappear  after  involving  more  of  the 
breast,  or  may  give  way  to  those  of  abscess.  Treatment. — Locally  :  rest ; 
suppoi-t ;  warmth  ;  moisture.  If  necessary,  the  milk  had  better  be  drawn 
off.  General  treatment  :  purgatives  ;  quinine  ;  belladonna  locally  ;  general 
rest  also. 

Lobular  Induration  of  Breast. — See  Paxnful  Mammary  Tumor. 

Malformation  of  Breast. — The  breasts  may  be  absent,  or  may  be  ex- 
cessive in  number  ;  or  they  may  occupy  strange  situations,  e.g.,  the  back 
or  groin. 

Tumors  of  the  Breast. — Under  this  head  will  be  noticed  such  new 
growths  as  are  not  carcinomatous,  viz.  :  1,  chronic  mammary  tumor,  in- 
cluding "painful  mammary  tumor;  "  2,  cysts  ;  3,  fibromata  ;  4,  enchondro- 
mata ;  5,  osteomata. 

1.  Chronic  Mammary  Tumoi — (Synonyms :  Adenoma — "  Hypertrophie 
partielle  " — Ilammary  Glandular  Tumor — Hydatid  Disease  of  the  Breast  (Sir 
A.  Cooper) — Sero-cystic  Sarcoma). — The  above  names  are  not  all  strictly  sy- 
nonymous ;  some,  such  as  adenoma,  are  applied  to  growths,  which  to  the 
naked  eye  appear  of  a  sohd,  fibrous  nature  ;  others,  e.g.,  sero-cystic  sarco- 
ma, are  appUed  to  tumors  consisting  chiefly  of  cysts  with  solid  growths 
inside  them.  These  latter  are  really  of  a  sarcomatous  nature  ;  the  true 
"  chronic  mammary  tumor"  is  more  of  the  nature  of  adenoma.  Causes. — 
Age,  most  frequently  from  20  to  30  ;  great  majoiity  of  cases  occui'  in 
single  women;  "blows,  squeezes,  lacteal  irritation,"  "hysterical  tempera- 
ment," "  uterine  irritation,"  "  sexual  excitement  of  an  irregular  kind  "  (Erich- 
sen).  Symptoms.— Commence  as  a  hard  nodvde,  usually  painless  and 
not  inbedded  in  the  mammary  gland,  but  movable  ;  may  be  peduncu- 
lated ;  growth  slow,  but  in  rare  cases  very  rapid ;  mammary  gland 
may  atrophy  ;  almost  always  single  ;  size,  perhaps  considerable  in  old 
tumors  ;  tumors  prominent,  not  attached  to  skin  ;  afterward  ulceration 
and  fungation.  Diagnosis. — 1,  vide  Lobular  Induration  of  Breast ;  2,  from 
cancer  by  (1)  slow  growth,  (2)  usual  freedom  from  pain  ;  3,  non-implication 
of  skin  ;  4,  healthy  state  of  glands  ;  5,  no  retraction  of  nipple  ;  6,  outline 
rounded  ;  7,  consistence  rather  elastic  than  strong  ;  8,  by  mobility.  When 
a  fungus  forms,  the  hole  in  the  skin  is  clean-punched.  Prognosis. — 
The  true  chronic  mammary  tumor  usually  grows  slowly,  and  does  not  re- 


44  BRONCHOCELE. 

turn  if  removed  ;  local  recurrence  is  common  in  the  case  of  the  sero-cystic 
sarcoma.  Treatment. — Absorbents,  ointments  of  iodine  and  the  iodides  ; 
pressiire  by  air-bags  and  spring  contrivances  :  these  means  are  praised  by 
some,  ridiculed  by  others.  Excision  ;  the  tumor  may  be  simply  enucleated, 
or  in  very  bad  cases,  especially  of  the  fungating  sero-cystic  kind,  the  gland  . 
may  be  removed  as  weU. 

Painful  Mammary  Tumor  includes  the  cases  often  described  as  Lobular 
Induration  of  the  Breast,  or  the  term  may  be  applied  only  to  such  "  chronic 
mamanary  tumors "  as  are  the  subjects  of  severe  pai-oxysmal  pains.  In 
Lobular  Induration  of  the  Breast,  one  or  more  lobes,  or  the  whole  breast,  is 
thickened  and  hardened,  but  there  is  no  tumor  distinct  from  the  breast, 
and  the  hard  part  does  not  project  ;  therefore,  the  hand  laid  Hghtly  on  the 
breast  does  not  feel  any  tumor.  Occurs  mostly  in  single  or  sterile  women  ; 
age,  from  25  to  45  ;  pain  often  shoots  along  course  of  intercostal  cutaneous 
nerves  going  to  gland  :  tenderness  on  pressure  over  their  course.  Treat- 
ment for  such  painful  conditions. — Support,  if  the  breasts  hang  dayra  ; 
pressure  ;  belladonna  plaster  ;  the  usual  constitutional  and  local  remedies 
for  neuralgia  ;  attention  to  the  generative  organs,  which  are  often  func- 
tionally deranged. 

2.  Cystic  Tumor  of  the  Breast  may  be  :  1,  simple,  or  2,  multiple,  or  3, 
combined  with  sarcoma,  or  4,  sanguineous,  or  5,  hydatid,  or  6,  milk- cysts. 
1.  Simple  cysts  vary  greatly  in  size  and  in  tension  ;  they  may  be  so  hard  as 
to  be  mistaken  for  solid  tumors ;  diagnosis  may  be  confirmed  with  a  trochar 
and  canula  ;  may  arise  from  obstructed  ducts.  2.  Multiple  cysts  are 
rare,  unless  combined  with  solid  growths.  3.  Cysto-sarcoma :  for  its 
symptoms  and  treatment  see  Chronic  Mammary  Tumor,  of  which  it  may  be 
regarded  as  one  form,  the  other  berag  adenoma.  4,  Sanguineous  cysts 
may  cause  bleeding  from  nipple.  6.  True  hydatids  are  very  rare  ;  the 
term  "  hydatid  disease  "  used  to  be  applied  to  sero-cystic  sarcoma  of  the 
breast,     6.  Galactocele,  vide  above 

3.  Fibromata, 

4.  Osteomata, 

5.  Enchondromata,  of  breast,  all  extremely  rare. 

Male  Breast  subject  to  same  diseases  as  female,  but  much  less  frequently 
attacked.  For  "Cancer  of  Male  Breast,"  refer,  if  necessary,  to  complete 
papers  by  Milton  ("Medico-Chirurgical  Transactions,"  vol.  xl.),  and  to 
Wagstaffe  ("Pathological  Transactions,"  vol.  xxvii.). 

Bronchoeele. — Two  kinds :  ordinary  and  exophthalmic  goitre ;  the 
former  may  be  endemic  or  sporadic,  simple  or  cystic,  and  it  may  be  acute. 
Causes. — Immediate  cause  unknown,  but  certainly  poverty  and  an  unhealthy 
mode  of  Hving  greatly  conduce  to  it.  Character  and  Effects. — Enlargement 
of  the  thyroid  gland  or  part  of  it,  fluctuating  if  cystic  ;  occasionally  causes 
dyspnoea,  dysphagia,  or  loss  of  voice,  or  displaces  neighboring  parts  ;  cysts 
usually  contain  serous  fluid  when  single,  grumous  fluid  when  multiple.    Ex- 


BUNION.  45 

ophthalmic  Goitre. — Pulsation,  anaemia,  prominence  of  eyeballs.  Diagnosis 
may  have  to  be  made  from  carotid  aneurism.  Treatment. — General  hygiene  ; 
high,  dry,  breezy  places  ;  iron,  iodine  internally  and  externally  ;  iodide  of 
potassium  ;  lead  iodide  and  mercuric  iodide  ointments  ;  pressure  ;  tapping 
cysts  and  injecting  them  with  iodine  or  iron  tincture  (  3  j-  to  3  ij-  with 
water);  pressin-e  ;  seton  (dangerous);  ligature  of  thyroid  arteries  ;  excision 
when  pressure  of  tumor  threatens  death  ;  for  acute  bronchocele,  if  the 
pressiu-e  gets  dangerous,  tap  any  cysts  and  divide  the  binding  cervical  fas- 
cia. D'Ancona  claims  to  have  cured  a  case  of  exophthalmic  goitre  by  gal- 
vanization of  the  cervical  sympathetic  {Dublin  Journal,  February,  1878). 

Bruise. — Possible  After-consequences. — Abscess,  contraction  or  shrivel- 
ling {e.g.,  of  the  ear  after  hsematoma),  permanent  thickening,  long-con- 
tinued pain  and  tenderness,  paralysis  of  nei've  or  muscle,  necrosis  or 
hypertrophy  of  bone,  a  weakness  and  liabihty  to  disease.  Treatment. — 
Pressure,  uniform,  equable,  and  tight,  especially  by  cotton-wool  and 
starch  bandage ;  stimulating  liniments,  ice,  cold  lotions ;  or,  in  severe 
cases,  warmth  and  exclusion  from  the  air.  Rest.  When  the  effusion  re- 
mains, try  friction,  kneading  or  pressure,  or  tap  antisejDtically. 

Bubo. — Causes. — Syphilis  (suppurating  bubo  caused  by  the  soft  chan- 
cre), gonorrhoea,  and  any  irritation  about  skin  of  external  genitals.  When 
there  has  been  no  visible  sore,  the  bubo  is  called  a  "sympathetic"  one. 
"  Bubon  d'emblee  "  means  a  syphihtic  bubo  from  absorption  of  vunis,  with- 
out intermediate  ulceration  ;  scrofulous  constitution  or  severe  local  disease 
of  genitals  aggravates  bubo.  Symptoms. — Those  of  inflammation  and  some- 
times suppuration  of  and  around  the  inguinal  glands  ;  suppuration  may 
greatly  undermine  and  destroy  skin  ;  chronic  or  acute.  Diagnosed  from 
deeper  abscesses  by  its  connections,  situation,  history,  and  course.  Prog- 
nosis.— Proper  treatment  will  often  prevent  abscess  ;  liability  to  slough  and 
open  arteries.  Treatment. — 1,  to  prevent  abscess  :  rest,  counter-irritation, 
blisters,  iodine-paint,  ex.  belladon.  and  glycerine  on  cotton- wool,  pressure, 
cold,  leeches.  General  treatment  for  cause  :  attend  to  bowels,  qtiinine, 
iron.  2,  when  abscess  forms  :  poultice,  foment,  then  open  freely  ;  destroy 
rotten  skin  ;  stimulating  ointments,  red  oxide  of  mercury  powder  or  oint- 
ment, ung.  resinse,  caustics  when  required  ;  iodoform. 

Creeping  Bubo  heals  at  one  side,  extends  at  other  ;  horse-shoe  shape. 

Bunion. — Thickening  of  bursa  over  head  of  metatarsal  bone  of  great 
toe  ;  occasionally  the  term  is  applied  to  any  enlarged  bursa  on  the  foot. 
Symptoms. — Fu-st  a  tender  spot,  then  swelling,  effusion,  liability  to  inflam- 
mation ;  suppuration,  sinus,  large  cavity  with  narrow  orifice,  thin  discharge  ; 
distortion  of  toe  outward,  displacement  of  flexor  longus  jDollicis  tendon  in 
same  direction  ;  changes  like  those  of  chronic  rheumatic  arthritis  in  the 
subjacent  joint,  or  more  serious  articular  disease  which  may  lead  to  fatal 
inflammation  of  the  foot  ;  may  be  starting-point  of  senile  gangrene. 
Prognosis. — Rarely    altogether   curable  when    it    has  long  suppurated. 


46  BURSJ3. 

Treatment. — Rest ;  remove  the  pressure  of  the  boot,  which  is  always  the 
cause  ;  restore  the  toe  to  natural  position  by  mechanical  contrivance  ;  it 
may  be  justifiable  to  divide  tendons  or  hgaments ;  corn  plasters,  soap 
plasters  ;  iodine  or  ointments  of  iodides  to  produce  resolution  ;  when  dis- 
charging, apply  stimulating  dressing,  e.g.,  ung.  resinse  ;  when  inflamed, 
poultices,  fomentations,  etc.  Nitrate  of  silver  solution  will  harden  tender 
skin. 

Burns,  including  Scalds. — Six  degrees  :  1,  cutaneous  hyperaemia, 
like  slight  erysipelas  ;  2,  blistering  ;  no  mark  left  after  recovery,  except 
occasionally  a  sUght  stain  ;  3,  true  skin  partly  destroyed  :  cicatrix,  but  no 
contraction  ;  4,  total  destruction  of  true  skin  :  possible  or  probable  great 
deformity ;  5,  muscles,  etc.,  destroyed ;  6,  a  whole  thickness  of  a  limb 
charred.  Symptoms  of  the  last  four  degrees  are  locally  those  of  in- 
flamed and  suppui-ating  wounds  casting  off  sloughs.  Constitutional 
Symptoms. — At  first,  those  of  shock  or  collapse ;  then,  within  forty-eight 
hours,  commences  the  second  stage  (of  reaction  and  inflammation).  The 
third  stage  (of  suppuration  and  exhaustion)  begins  in  about  a  fortnight. 
In  the  inflammatoi-y  stage  there  are  fever,  and  hability  to  various  com- 
plications, peritonitis,  pleuritis,  pneumonia,  bronchitis,  arachnitis,  conges- 
tion of  brain,  ulceration  of  the  duodenum.  The  symptoms  of  these 
special  affections  are  not  peculiar,  but  liable  to  be  obscure.  Third  stage  : 
hectic,  same  visceral  lesions  as  those  of  second  stage.  Inflammations  are 
of  a  low  tyj)e.  Erysipelas,  pyaemia,  and  tetanus.  Ulceration  of  the  duo- 
denum occurs  most  frequently  in  the  second  stage,  and  is  found  in  12  per 
cent,  of  fatal  cases  of  burns :  its  symptoms  are  epigastric  tenderness  (not 
a  valuable  sign)  and  hemorrhage  from  the  anus.  Prognosis. — Depends  on 
age,  extent  of  surface  injured,  and,  to  a  less  degree,  upon  depth.  Most 
serious  in  young  children.  Treatment. — Locally:  rest;  protect  part 
from  air  ;  cotton  wadding,  oil,  Hnseed-oil  and  lime-water,  zinc  ointment ;  or 
rags  dij)ped  in  and  kept  constantly  wet  with  solution  of  silver  nitrate 
(gr.  X.  ad  3J.),  or  with  a  concentrated  solution  of  carbonate  of  soda; 
starch,  flour,  balsam  of  Peru,  etc.  Afterward  the  treatment  of  simple 
ulceration.  Guard  against  contraction  from  cicatrization.  Vide  Cicatkix. 
Terebene,  carbolic  lotion,  and  oakum  for  offensive  discharges.  Don't  ins- 
tate by  dressing  too  often.  Constitutional  treatment :  in  stage  of  col- 
lapse, opium,  morphia  subcutaneously,  full  doses ;  stimulants  cautiously ; 
warmth  ;  chloroform  if  necessary  at  first  di'essing.  In  later  stages  watch 
for  and,  so  far  as  the  patient's  state  admits,  treat  the  complications. 
Warmth  externally  for  convulsions.  Opium  for  diarrhoea,  but  keep  the 
bowels  regular.  Bloodletting  sometimes  for  the  visceral  inflammations. 
Diet  chiefly  of  milk.  Judicious  stimulants,  good  food  and  tonics  often 
indicated  ;  fresh  air. 

Bursae. — Situations  of  chief :  acromion,  oleci'anon,  great  trochanter, 
tuberosity  of  ischium,  beneath  psoas,  lower,  superior,  and  outer  parts  of 


CALCULUS. 


47 


patella,  condyles  of  femur,  popliteal  space,  tuberosity  of  tibia,  and  the  os 
calcis.  They  also  occur  on  almost  any  hard  prominence,  especially  if  sub- 
ject to  pressure,  and  under  any  tendon  which  glides  over  bone. 

Diseased  Conditions  of  BuEs.a:. — Four,  viz. :  1,  simple  enlargement  with 
fluid  contents  ;  2,  enlargement  and  solidification ;  3,  enlargement  and 
formation  of  melon-seed  bodies ;  4,  inflammation.  As  a  type  of  all  bursse, 
let  us  take  the 

Bursa  Patella. — All  the  above  diseases  may  occur  here,  and  are  the 
result  of  undue  and  repeated  pressure.  Inflammation  may  follow  a  blow 
only,  but  especially  a  blow  on  bursa  already  enlarged.  1.  Simple  Enlarge- 
ment.— A  globiilar  swelling,  obviously  in  front  of  patella  or  Hg.  patellae, 
and  therefore  not  'in  the  joint.  Fluctuation  sometimes,  or  even  transpa- 
rency. Usually  painless.  Stiffness.  Perhaps  no  trouble  whatever.  2. 
Solidification. — May  be  judged  by  the  feel,  or  detected  after  incision.  3. 
Melon-seed  bodies  may  cause  a  crackling  feel.  4.  Inflammation  causes  heat, 
redness,  etc.,  and  leads  almost  always  to  abscess.  Treatment. — For  1. 
Remove  cause,  iodine  or  blistering  externally,  tapping  simply,  or  with  in- 
jection of  tincture  of  iodine  (  3  j.)  ;  seton;  free  incision  with  gentle  but  firm 
compression.  2.  Excise  the  solid  bursa.  In  dissecting  it  out,  remember 
the  absolutely  close  proximity  of  the  joint.  3.  Melon-seed  bodies  are  to 
be  let  out  by  incision  if  the  bursa  is  troublesome.  4.  For  inflammation — 
leeches,  fomentations,  poultices,  rest,  elevation,  back-splint.  When  abscess 
forms  incise  fi-eely.  Suppuration  may  cause  cellulitis  all  about  knee, 
bursting  of  pus  into  neighboring  tissues  or  joint,  or  disease  of  patella. 
Enlarged  bursa  over  olecranon  often  causes  diffuse  cellulitis  of  forearm. 
Bursa  in  popliteal  space,  and  beneath  semi-membranosus,  very  liable  to 
communicate  with  knee-joint.  Hence  caution  in  tapping  ;  antiseptic.  En- 
larged bursa  with  liquid  contents  can  be  easily  reduced  by  elastic  pres- 
sure. Bat  this  elastic  pressure  requires  experience  and  care  to  be  used, 
with  perfect  safety. 

Calculus. —  Urinary  Deposits. — Table  of  two  classes,  organic  and  inor- 
ganic : 


Name. 

Characters. 

Causes. 

Symptoms. 

Treatment. 

o 
S 
S 

m  o 

S3 

m 

Pinkish  yellow,  red,  or 

lateritious     (brick-dust) 
sediment ;  urine  scanty, 
acid,    and   high-colored. 
The  precipitate,   before 
subsiding,  forms  a  cloud 
ill  the  urine,  which  clears 
off  when  heated. 

Crystalline  form— uric 
acid,     mostly     rhombic 
prisms  and  plates. 
"Gravel." 

1.  Rapid  waste  of  tis- 
sues, e.g.,  as  in  fevers; 
2,  excess  in  nitrogenous 
food  ;    3,  dyspepsia  ;  4, 
obstructed  perspiration  ; 
5,  congestion  of  the  kid- 
neys    (Golding      Bird). 
Also  imperfect  respira- 
tion.    Cold  weather  will 
precipitate  urates  some- 
times      from      healthy 
urine. 

Those  of  the 
causes.     Some- 
times    also     a 
slight   burning 
feel  in  passing 
water. 

Treat     the 
causes.        Moder- 
ate   animal  food. 
Plenty    of    exer- 
cise,     fresh    air, 
particular    atten- 
tion to  the  diges- 
tion, etc.     Fried- 
rickshall       and 
Vichy  waters. 

Urates. — Minute  spheres  with  acicular  spiculse  of  uric  acid  projecting  from  them. 

48 


CALCULUS. 


Organic  and  Inorganic  Calculi — (Continued). 


Name. 

Characters. 

Causes. 

Symptoms. 

Treatment. 

a 

•s 
1 

o 

Crystalline  forms :  1, 
quadratic  octahedra ;  2, 
dumb-bell  crystals. 

"Nervous    exhaus- 
tion ;  "  dyspepsia  ;  over- 
work :  mental   distress ; 
excess  of  saccharine  food 
or  alcoholic  Equors. 

Those  of  the 
causes.     Occa- 
sionally, loss  of 
sexual  vigor,  or 
disorder  of  the 
sexual       func- 
tions. 

Treat     the 

causes.      Regular 
diet,         exercise, 
etc.    Mineral 
acids. 

■D 

«> 
to 

1 

1.  Phosphate  of  Lime. 
— White,    cloudy  mass. 
Crystals:     spherules, 
dumb-bells,    rosettes, 
oblique     hexagonal 
prisms.    2.  Phosphate  oj 
Ammonia  and  Magnesia 
(triple  phosphate'). 
Crystals   (large) :    trian- 
gular, truncated  prisms, 
four-sided  prisms,  irreg- 
ular   six-sided     plates ; 
stellate     crystals     when 
ammonia  hasbeenadded. 

Alkaline  urine  is  the 
immediate  cause.     It  is 
caused   by  injuries   and 
diseases  of  the  bladder, 
especially  paralysis  and 
catarrhal  inflammations ; 
renal  inflammation ;  spi- 
nal   injury    or    disease. 
Nervous  exhaustion;  ex- 
cessive use  of   alkalies  ; 
the    alkalinity    of    the 
urine  is   said   to   result 
from  the  metamorphosis 
of  urea  into  carbonate  of 
ammonia. 

Urine  is  of- 
fensive, and  of- 
ten      contains 
muco-pus. 
Signs  of  causa- 
tive disease. 

Treat    the 
causes.   See  Dis- 
eases OF  Blad- 
der, etc. 

4 

1 

a 

Small    and  delicate 
crystalline  spherules. 
Drum-sticka. 

The  causes  which  de- 
termine  the  change    of 
urea  into   carbonate   of 
ammonia. 

No    special 
sympt  oms 
known.    Depo- 
sit rare. 

Treat   the  con- 
ditions which  ac- 
company it. 

13 

Urine  a  dirty  red  color; 
after  standing,  a  slightly 
flocculent,  brownish  sed- 
iment.    Heat  coagulates 
the  albumen.  There  may 
be  blood  enough  to  form 
a  clot ;  then  the  urine  is 
dark  brownish  red.     Or 
the  blood  may  be  quite 
unmixed  with  the  xiriue. 

1 .  Kidney  disease.  Cal- 
culi, congestion,  inflam- 
mation,   injury,   scurvy, 
the  Bilharzia    capensis. 
Malaria  may  cause  inter- 
mittent     hematuria. 
Blood   from  the  kidney 
is  generally  mixed   uni- 
formly  with   the  urine, 
and  forms    blood-casts. 
2.    Bladder     afiections : 
injuries,  stone,  tumors. 
Blood  from  bladder  of- 
ten flows  pure  after  the 
urine.        3.    Urethra: 
blood  pure,   and  comes 
before  or  with  urine,  or 
without  urine  at  all. 

Those  of 
cause.     Use 

Heller's  test  for 
blood.         Heat 
urine,  then  add 
KHO  and  heat 
again.     The 
phosphates 
then  fall  down 
with  the  color- 
ing   matter    of 
the  blood.   The 
sediment  has  a 
dirty  red  color 
by       reflected, 
and  a  splendid 
blood-red  color 
by  transmitted 
Ught. 

Rest  and  inter- 
nal styptics,  e.g., 
gallic     and     sul- 
phuric acids,  ace- 
tate of  lead  with 
opium.    Dry  cup- 
ping the  loins  also 
in    renal  hasmor- 
rhage.      For  vesi- 
cal    haemorrhage 
use  similar  treat- 
ment    and    local 
remedies :    ice  to 
perinfeum        and 
epigastrium    and 
in   rectum.        Do 
not       catheterize 
unless  there  is  re- 
tention   of  urine. 
If  the    clots  will 
not    come    away 
without    interfe- 
rence,   use,    cau- 
tiously.    Clover's 
exhausting  appa- 
ratus for  lithoto- 
mj',    or  a  syringe 
and  full-sized  ca- 
theter.       Ruspi- 
ni's  styptic. 

CALCULI. 


49 


Name. 

Characters.     . 

Causes. 

Symptoms. 

Treatment. 

Pus-corpuscles,  under 
the      microscope,       are 
spheroidal  and  granular. 
The   pus  generall}'  sub- 
sides as  a  dense  layer  of 
a  '  *  pale  greenish  cream- 
color,''    which     can    be 
mixed   thoroughly    with 
the    urine    by    shaking. 
Not    affected   by  acetic 
acid.     Forms  a  translu- 
cent  jelly   when    liquor 
potassre  is  added.     The 
urine  is  albuminous. 

Abscess,      ulceration, 
or  merely  catarrh  of  any 
part  of  the  urinary  pas- 
sages.     1.  Pus  from  the 
kidneys  is  usually  dif- 
fused  throughout  urine 
passed.       2.    Pus    from 
bladder  is  mostly  mixed 
with    mucus.       3.    Pus 
from  an  abscess  is  usu- 
ally variable  in  quantity, 
and  not  equally  dift'used. 

Those  of  the 
cause. 

Treat    the 
cause. 

B 

•rH 

Epithelial  cells  lining 
urinary    passages.       See 
works  on  general  Anat- 
omy.    Often  in  form  of 
casts. 

Kidney  disease.      Ul- 
ceration or    catarrh    of 
bladder. 

Those  of 
caujse. 

Treat  cause. 

Fibi'ine  is  sometimes  present  in  the  form  of  floccvili.  Or  it  may  form 
fibrinous  casts  of  the  tubuli  uriniferi.  For  information  about  casts,  vide 
medical  works  on  the  kidney.  Echinococcocysts  are  sometimes  found  in 
the  urine.  Give  turpentine  in  large  doses.  The  above  table  has  been  con- 
structed chiefly  with  the  aid  of  Thompson,  Druitt,  and  Niemeyer.  In  cancer 
of  the  bladder  cancer-ceUs  and  debris  are  sometimes  found  in  the  urine. 

Calculi. — There  are  seven  mineral  substances  of  which  urinary  calcvdi 
may  be  formed.,  A  calculus  may  consist  of  several  of  these  materials  in 
layers,  or  of  one  only.  1,  Lithate  of  ammonia ;  2,  lithic  or  uric  acid  ;  3, 
oxalate  of  lime  ;  4,  xanthic  or  uric  oxide  ;  5,  cystic  oxide  ;  6,  phosphate  of 
lime  ;  7,  triple  phosphate.  For  the  causes  of  the  presence  of  an  abnormal 
amount  of  some  of  these  substances  in  the  urine,  see  table  of  urinary  de- 
posits. The  nucleus  or  centre  of  each  calculus  may  be  formed  first  in  the 
kidney  or  in  the  bladder,  or  it  may  be  a  foreign  body.  Poverty,  certain 
locahties,  and  the  male  sex  are  great  predisposing  causes  of  stone  in  the 
bladder.     Negro  race  remarkably  exempt. 


Table  of  Calcuix 


Name. 

Physical  Characters,  etc. 

Chemical  Characters. 

Lithate 

of 

Ammonia. 

Occurs  rarely,  except  in  chil- 
dren. Gray,  smooth,  dusty,  non- 
laminated  appearance. 

Soluble  in  boiling  water.  Add  HCl  to  solution 
and  you  get  a  precipitate  of  uric  acid.  Heat  with 
potassium  carbonate  :  ammonia  escapes.  Blow- 
pipe burns  it  away. 

< 

g 

Smooth  or  warty.     Yellowish 
or  brownish.     Concentric  struc- 
ture. 

Gives  off  no  ammonia  when  heated  with  KHO. 
Evaporate  to  dryness  with  nitric  acid.  Cool,  and 
add  a  little  NH3  ;  the  characteristic  deep  purple- 
red  murexide  is  then  obtained.  Blow-pipe  burns 
uric  acid  away. 

50 


CALCULI. 

Table  of  Calculi — (Continued). 


Name. 


Physical  Characters,  etc. 


Rough,  warty,  "  mulberry  " 
appearance.  Very  bard.  Dark 
"  blood-stained." 


Chemical  Characters. 


Easily  soluble  in  nitric  acid.  Boil  long  in  a 
solution  of  potassium  bicarbonate,  neutralize  care- 
fully with  nitric  acid  ;  then  white  precipitates  can 
be  formed  with  solutions  of  lime,  lead,  or  silver. 
Blow-pipe  reduces  it,  first  to  calcium  carbonate, 
then  to  quick-lime.  Heat  on  platinum  foil  and  it 
chars.     Then  add  HNO,  and  it  effervesces. 


Has  a  wavy  appearance,  espe- 
cially when  fractured,  Changes 
color  with  age  from  pale  yellow 
to  brown,  gray,  or  green.  Ex- 
tremely rare.  Contains  sul- 
phur. 


Dissolves,  in  great  part,  in  ammonia :  its  solu- 
tion then  deposits,  by  spontaneous  evaporation, 
six-sided  prismatic  and  tubular  crystals.  Dis- 
solve in  strong  caustic  potash.  Boil,  and  add  a 
little  solution  of  lead  acetate  :  a  black  precipitate 
of  sulphate  of  lead  falls. 


Section,        lustrous       bright 
brown.     Most  extremely  rare. 


Has  a  peculiar  deep  yellow  color,  when  its  solu- 
tion in  nitric  acid  is  evaporated  to  dryness  ;  char- 
acteristic. 


)    to    «    ID 

1  -^  ^  ■-- 


Chalky,    soft,    brittle,   lami- 
nated. 


"Fusible  calculus":  melts  in  the  blow-pipe 
flame.  Dissolve  in  nitric  acid  and  add  excess  of 
ammonia  :  white  precipitate. 


Phosphate  of  lime  and  triple  phosphate  very  rarely  occur  separately. 

Fibrinous  calculi  smell  of  burnt  feathers  when  burnt,  and  are  stained 
bright  yellow  by  nitric  acid. 

Uric  acid  forms  the  nucleus  of  most  "  alternating  "  calculi. 

The  nature  of  the  stone,  while  still  in  the  bladder,  may  be  guessed  at 
by  considering  the  urine  and  any  deposit  from  it.  The  urates  are  foiTued 
from  acid,  the  phosphates  from  alkaline  urine  [vide  Table  of  Urinary 
Deposits). 

Symptoms  of  calculus  in  the  bladder. — (Often  so  trifling  as  to  attract 
no  attention  for  a  long  time.)  1,  Pain  radiating  from  bladder  to  perinseum 
and  in  glans  penis,  especially  after  micturition  ;  2,  riding  or  jolting  may 
aggravate  the  pain  by  shaking  stone  about ;  less  pain  when  prostate  is 
much  enlarged ;  3,  urine  sometimes  stops  fiowing  suddenly  ;  4,  frequent 
micturition ;  5,  in  children,  incontinence  of  urine  ;  6,  blood  in  urine  ;  7, 
signs  of  vesical  catarrh  ;  8,  prolapsus  ani ;  9,  priapism.  Many  of  these  symp- 
toms are  often  absent.    For  physical  signs  we  employ  the  process  called 

Sounding. — The  sound  should  have  a  short,  sharply  curved  beak,  and  is 
best  hollow.  Warm,  oil,  and  introduce.  Hold  lightly  and  gently.  Push 
backward  and  forward,  and  from  side  to  side.  Then  turn  point  down- 
ward, to  examine  base  of  bladder.  The  finger  in  the  rectum,  or  suddenly 
letting  the  urine  flow  through  the  sound  will  sometimes  assist.  Points  to 
be  ascertained  :  1,  presence  or  absence  of  stone  ;  2,  size  ;  3,  number ;  4, 
nature  ;  5,  whether  the  stone  is  encysted  or  not ;  6,  state  of  bladder  as  to 


CALCULI.  51 

rugosity.  Size  and  number  are  best  found  by  seizing  and  measuring  with 
a  litho trite.  Nature  best  judged  by  considering  the  urine  and  the  patient's 
age  and  constitution.  Fallacies  result  from  mistaking  a  fasciculated  blad- 
der or  the  feel  of  some  bony  pelvic  prominence  for  a  calculus.  The  stone 
should  be  heard  as  weU  as  felt.  A  stone  may  be  hidden  away  in  a  sac- 
culus.  It  there  keeps  always  in  one  position,  and  perhaps  is  only  felt 
occasionally  or  not  at  all.  "  The  surgeon  should  always  remember  that 
when  irritation  at  the  neck  of  the  bladder  arises  from  stone  it  is  referred 
to  the  glans  penis  ;  when  from  disease  of  the  bladder,  to  the  organ,  itself  ; 
and  when  from  disease  of  the  prostate,  to  the  perinseum  or  rectum " 
(Bryant). 

Treatment. — 1,  Palliative  :  treat  the  complications,  e.g.,  vesical  catarrh  ; 
recumbent  position  ;  decoction  of  triticum  repens.  2,  Operative  :  as  lithon- 
tripsis  is  not  yet  of  any  value,  refer  to  articles  Lithotomy,  Lithotkity,  and 

LiTHOLAPAXY. 

Calculus  in  the  Kidney. — Causes. —  Vide  Table  of  Urinary  Deposits. 
Position. — ^They  may  occur  as  small  infarctions  in  the  tubules,  or  as  stones 
of  various  sizes,  single  or  multiple,  in  the  pelvis  and  calyces,  often  forming 
a  cast  of  the  pelvis  and  its  offsets.  Symptoms  and  Course. — Pain  in  the 
back  ;  blood,  pus,  or  "  gravel "  in  vu'ine  ;  sometimes  intense  pain  (renal 
colic),  caused  by  passage  of  a  calculus  down  the  ureter  into  the  bladder  ; 
pyehtis.  Treatment. — When  an  abscess  forms  it  has  been  found  sometimes 
practicable  and  justifiable  to  cut  down  upon  and  remove  the  stone.  For 
the  renal  colic,  use  opium  boldly,  chloroform,  and  warm  baths. 

Calculus  in  the  Prostate.  — Origin :  either  descends  from  bladder,  or 
forms  first  in  prostate.  Number,  1  to  100  ;  size,  grain  of  sand  to  cherry- 
stone ;  faceted  ;  color,  various  ;  consistence,  various  ;  structure,  usually 
concentric  layers ;  chemistry,  phosphate  (rarely  carbonate)  of  lime  ;  posi- 
tion, projecting  into  or  near  the  ui'ethra  usually,  but  sometimes  near 
circumference  of  gland,  and  occasionally  even  partly  in  bladder  and  partly 
in  prostate.  Symptoms. — Those  of  irritation,  inflammation,  or  abscess  of 
the  prostate,  according  to  their  effect ;  semi-erection  of  penis,  and  dif- 
ficulty in  seminal  ejaculation.  Calculus  can  possibly  be  felt  by  sound  in 
the  urethra  or  finger  in  rectum.  Treatment. — Remove,  if  possible,  by 
urethral  forceps,  or  operate  as  for  median  lithotomy  ;  but  do  not  operate 
when  the  calculi  are  small,  very  numerous,  or  only  to  be  felt  per  rectum. 
When  operating,  see  if  there  be  any  calculus  in  the  bladder  also. 

Calculus  in  the  Urethra. — Usually  descends  from  bladder,  but  may  be 
formed  in  sitd  (then  usually  behind  a  stricture).  Symptoms. — Pain,  ob- 
struction, or  retention  of  urine.  If  not  relieved,  dilatation  of  urethra, 
extravasation,  abscess,  and  urinary  fistula,  through  which  stone  may  pass. 
Treatment.— 1,  Push  forward  with  finger  and  thumb  ;  2,  extract  with  ure- 
thral forceps,  wax  bougie,  or  some  specially  devised  instrument,  if  neces- 
sary sUtting  up  meatus  urinarius  ;  or,  3,  push  back  stone  to  posterior  part 


52  CANCEB. 

of  urethra,  and  do  median  lithotomy.  If  there  is  not  serions  obstruction, 
a  Httle  patience  will  sometimes  allow  the  urine  to  wash  the  stone  right  to 
the  meatus  within  twenty-four  hours.  In  other  cases  delay  is  highly 
dangerous. 

Calculus  in  Female  has,  besides  many  of  those  of  male,  these  special 
symptoms,  viz. :  1,  bearing-down  pains  ;  2,  incontinence  of  mine.  Diagnose 
carefully  from  uterine  disease,  by  sounding  and  vaginal  examination. 
Prognosis. — Liability  to  ulceration  into  vagina,  and  consequent  vesico- 
vaginal fistula.  Treatment. — Remove  calculus.  Three  classes  of  methods, 
viz.  :  1,  urethral  dilatation  ;  2,  lithotrity  ;  3,  lithotomy.  The  dilatation  is 
best  done  with  a  screw  three-bladed  dilator  {vide  also  articles  Lithotomy 
and  Lithotkity).  Danger  of  incontinence  if  the  urethra  is  dilated  too 
much.  The  limits  of  size  for  dilatation  should  be  a  diameter  of  one  to  one 
and  a  half  inch  for  adults,  and  half  as  much  for  children.  Slow  dilatation 
almost  always  followed  by  incontinence  (refer  to  Walsham,  "  St.  Bartholo- 
mew's Hospital  Reports,"  vol.  xi.). 

Cancer. — The  term  is  commonly  used  as  if  synonymous  with  "  mahg- 
nant,"  and  therefore  including  other  new  growths  besides  "  carcinomata." 
Characters  of  3Ialignancy. — A  cancer  tends  to  1,  infiltrate  neighboring  tis- 
sues ;  2,  recur  ;  3,  affect  lymphatic  glands  ;  4,  be  followed  by  secondary 
deposits  ;  and  if  the  cancer  be  left  long  enough,  all  these  four  events  are 
pretty  sure  to  take  place.  Cancers  also  tend  to  soften  and  ulcerate,  and 
"there  is  scarcely  a  tissue  or  an  organ  which  they  may  not  invade." 
Causes. — There  can  be  little  doubt  but  that  hereditary  influence  has  some 
effect  in  this  as  in  the  liability  to  most  other  diseases.  Still  the  cancer  at 
its  origin  is  probably  local,  and  various  local  irritations,  such  as  blows, 
smoking  clay  pipes,  decayed  and  rough  teeth,  etc.,  can  often  be  traced  as 
exciting  causes.  Soft  cancer  occurs  chiefly  in  youth,  hard  cancer  in  middle 
age.  It  is  certain  that  affections  at  first  pure  chi'onic  inflammation  in  their 
nature  sometimes  pass  into  cancer.  Symptoms. — Those  of  a  new  growth 
differing  from  an  innocent  tumor  in  more  or  less  of  the  following  charac- 
ters :  1,  it  tends  to  infiltrate  ;  2,  to  involve  neighboring  tissues  ;  3,  to  at- 
tack neighboring  lymphatic  glands  ;  4,  it  gi'ows  more  rapidly  than  innocent 
tumors  ;  5,  it  is  usually  more  painful ;  6,  it  tends  to  soften  and-  ulcerate  ; 
7,  it  has  the  pecuhar  features  of  one  of  the  varieties  of  cancer.  Prognosis 
{Vide  Cancee  of  Breast,  etc.). — Epithelial  cancers  kill,  on  the  average,  in 
fifty -three  months  ;  scuThus  in  thirty-two  (Sibley).  Soft  cancer  is  still 
more  rapid.  Cancer  kills  by,  1,  hemorrhage  ;  2,  interference  mechanically 
with  vital  organs  ;  3,  general  infection  of  blood  and  consequent  cachexia, 
etc.  Histology. — Every  cancer  consists  of  cells  lying  in  the  interetices  of  a 
network  of  fibrous  tissue  ;  the  network  may  be  close  or  open,  strong  or 
weak  ;  the  cells  are  of  two  kinds  :  one,  the  larger,  are  of  epithelial  origin  ; 
the  other,  the  "  small  cell  formation,"  of  connective-tissue  origin.  It  may 
here  be  mentioned  that  the  cells  of  a  sarcoma  are  all  of  connective  tissue 


CANCEB.  53 

origin,  and  primarily  directly  connected  with  the  mesh- work  in  which  they 
He  (  Vide  Special  Varieties  of  Cancer).  Cancer- juice  is  fluid  containing  can- 
cer-cells and  often  oil-particles  and  debris.  Varieties  of  Cancer. — Some  of 
the  sarcomata,  and,  indeed,  exceptionally  almost  any  kind  of  tumor  may 
have  most  of  the  characters  of  malignancy.  In  these  cases,  the  characters 
are  usually  so  modified  as  to  cause  a  condition  spoken  of  as  "  semi-mahg- 
nant."  But  most  cancers  are  carcinomata.  There  are  five  varieties  of  car- 
cinoma, viz.  :  1,  hard  ;  2,  soft ;  3,  colloid  ;  4,  squamous  (ordinary)  epithe- 
hal ;  5,  cylindrical  epithelial  cancer  ;  besides  villous,  melanotic,  and  osteoid 
cancers. 

Cancer,  Haed — Scikkhus. — The  fibrous  part  preponderates  over  the 
cell  elements.  Pathology. — Hard,  section  concave,  white  or  gray,  dotted 
with  yellow  points  ;  no  defined  margin  ;  juice.  Either  tuberous  or  infil- 
trating ;  "  tuberous"  means  "  forming  a  distinct  nodule."  When  infiltrat- 
ing, the  neighboring  parts  are  hard,  adherent,  and  often  drawn  in ;  infil- 
tration of  skin  with  tubercles,  a  very  valuable  clinical  symptom.  Parts  of 
the  cancer  often  atrophy,  or  even  slough.  The  cancerous  ulcer  is  irregu- 
lar, fetid,  with  thick,  hard  edges.  Locality. — Breast,  skin,  rectum  ;  found 
also  in  testicle,  tonsil,  eye,  etc. 

Cancer,  Soft — ENCEPH.u:.orD. — Fibrous  part  small ;  cells  abundant ; 
special  characters  of  other  varieties  absent ;  not  distinct  in  nature  from 
scirrhus.  If  a  scirrhus  be  removed,  cancer  often  recurs  as  encephaloid. 
Consistence,  often  as  soft  as,  or  even  much  softer  than,  brain  ;  color,  white, 
creamy,  or  blood-stained.  When  connected  with  bone  or  periosteum, 
liable  to  contain  bony  plates  or  even  a  complete  bony  framework  ;  often 
contains  large  blood-cysts  ;  may  be  encapsulated  ;  soft  and  fluctuating. 
Puncture  lets  out  blood  and  often  cancer-juice  as  well.  May  ulcerate  and 
fungate  as  a  bleeding  mass  ;  grows  fast,  and  is  covered  by  large  cutaneous 
veins,  owing  to  its  obstructing  deeper  veins  ;  large  vessels  and  nerves  not 
generally  compressed;  amount  of  pain,  variable  ;  "cancer  of  young  life." 
Locality. — Bones,  female  breast,  eye,  testicle  ;  attacks  also  utenis,  bladder, 
etc. 

Cancer,  Colloid — Alveolar  Cancer. — Its  carcinomatous  nature  doubt- 
ful ;  consists  of  a  stroma  of  wide  meshes,  with  rounded  or  oval  nuclei ; 
meshes  contain  a  jelly-Hke  substance,  besides  cells,  some  of  which  have 
concentric  laminae  Uke  an  oyster-shell ;  to  the  naked  eye  this  cancer  has  a 
markedly  jelly-like  appearance.  Locality. — Peritoneum,  ovary,  breast, 
Hmbs,  parotid,  rectum  ;  in  alimentary  canal,  it  is  said  to  arise  from  Lieber- 
kuhn's  follicles. 

Cancer,  Squamous  Epithell\l,  or  ordinary  epitheHoma. — Least  malig- 
nant of  the  carcinomata  ;  cells  flattened  hke  those  of  epidermis  ;  tendency 
to  arrange  themselves  in  "nests."  First  appearance,  usually  a  hard  lump 
or  wart,  which  may  be  dry  for  a  long  time,  but  usually  ulcerates  sooner  or 
later.     Ulcer  has  hardened,  elevated  edges,  and  often  an  excavated  base  ; 


54  CANCER. 

occasionally  cauliflower-like  ;  glands  slow  to  be  affected  ;  infection  of  the 
system  slower  still.  Locality. — Places  where  skin  and  mucous  membrane 
meet,  e.  g.,  lips,  eyelids,  anus,  etc.  ;  also  warts  on  the  skin,  back  of  hand, 
front  of  leg,  prepuce  (from  irritation  of  soot),  tongue.  Life  usually  de- 
stroyed by  local  causes.  Cancer  should  be  removed,  even  if  glands  are 
somewhat  enlarged,  for  the  enlargement  may  be  merely  the  result  of  irrita- 
tion or  inflammation.     If  done  early,  there  is  fair  hope  of  non  recui-rence. 

Cylindeical  Epithelial  Cancer  occurs  in  mucous  membranes.  Both 
primary  and  secondary  deposits  contain  cyhnders  of  cyhndrical  epithelium, 
like  the  structure  of  mucous  membrane  itself. 

Villous  Cancer. —  Vide  Diseases  of  Bladder. 

Osteoid  Cancer. — Here  not  only  the  primary  tumor  has  a  skeleton  of 
bone,  but  bone  also  appears  in  the  secondary'  deposits. 

Melanotic  Cancer  is  simply  cancer  with  deposits  of  pigment  in  the  cells. 
Its  primary  seat  is  usually  a  part  originally  highly  pigmented,  e.g.,  a  dark 
mole.     May  be  either  carcinoma  or  sarcoma. 

Treatment  of  Cancer. — Constitutional.  Tonics,  especially  iron.  Ano- 
dynes necessary  in  later  states.  Diet  ample  and  nutritious.  Local  treat- 
ment.— Support  and  rest  when  not  actively  interfering  with  it ;  layer  of 
cotton- wool  and  bandage  ;  iodine,  opium,  and  lead  retard  growth  of  tumor  ; 
amadou  plaster  ;  for  sloughing,  a  bread  poultice  with  powdered  charcoal ; 
terebene  ;  wash  ulcers  with  a  weak  solution  of  zinc  chloride  and  laudanum  ; 
tepid  lotion  of  chlorate  of  potash  to  be  used  frequently  ;  lotion  of  citric 
acid  said  to  be  sedative  to  epithelial  cancers.  For  oedema  of  a  limb  caused 
by  pressure,  soft  bandages.  For  hemorrhage,  perchloride  of  iron,  or 
hgature  of  any  bleeding  artery,  or  bathing  with  water  as  hot  as  it  can  be 
borne.  For  pain,  extract  of  belladonna  with  glycerine,  locally.  Apply  to 
a  painful  cancerous  sore  morphia  and  glycerine  on  lint,  or  iodoform ; 
chloral  or  morphia  internally.  Question  of  operating. — Objects  of  opera- 
tion— 1,  to  prolong  life  ;  2,  to  give  an  interval  of  ease  and  usefulness. 
Eeasons  for  not  operating — 1,  unhealthy  condition  of  patient,  e.g.,  severe 
kidney  or  lung  disease  ;  2,  diffuse  and  wide  infiltration  of  a  cancer  ;  3,  can- 
cerous cutaneous  tubercles  ;  4,  disease  of  glands  which  cannot  themselves 
be  removed  ;  5,  considerable  adhesion  of  a  scirrhous  breast  to  pectoral  mus- 
cle ;  6,  more  than  one  tumor  (except  in  rare  and  chronic  cases)  ;  7,  cancers 
beneath  scalp.  If  the  conditions  are  favorable,  the  sooner  the  cancer  is 
removed  the  better.  It  should  be  removed  freely,  the  neighboring  parts 
carefully  examined,  and,  in  many  cases,  treated  with  caustics,  e.g.,  zinc 
chloride  (gr.  xx.  to  |  j.).  Suspicious  glands  should  be  removed  entire. 
Ecraseur  instead  of  knife  in  cancer  of  tongue,  neck,  or  uterus,  etc.  ;  gal- 
vanic cautery  to  cancers  of  skin  ;  caustics  ;  Maissonneuve's  caustic  arrows  ; 
injection  of  dilute  acetic  acid  (1  to  3),  its  efficacy  doubtful.  Injection  of 
bromiae  in  alcohol  (iTl,.  v.  to  |  j.).  Esmarch  and  BiUroth  have  treated  can- 
cer with  some  success,  by  increasing  doses  of  arsenic,  long  continued. 


CASTRATION.  55 

Cancrum  Oris  (or  Gangrenous  Stomatitis). — A  phagedenic  ulceration 
of  the  cheek  in  childhood  (second  to  eighth  year).  Causes. — Usually  a  se- 
quel of  one  of  the  exanthemata  ;  low,  damp  lodgings,  bad  air,  food,  etc!  ; 
mercur)^  to  excess  in  feeble  constitutions.  Symptoms. — Mild  form  marked 
by  small  gray,  sloughy,  foul  ulcers  on  inside  of  cheek,  with  red  gums  and 
foul  breath.  The  typical  form  presents  a  slough  reaching  right  through 
cheek  ;  skin  white,  swollen,  hard,  with  a  red  blush  in  centre.  Internally, 
a  foul,  sloughing  ulcei",  opening  into  mouth  ;  foul  odor  ;  gums  swollen  and 
ulcerated.  Child  suffers  Httle,  and  dies  comatose.  Pecuhar  moving  bodies 
in  blood  in  a  case  of  noma ; '  virulent  infectiousness  of  such  blood  (San- 
som).  Prognosis. — Of  the  severe  form,  only  one  in  twenty  recovers.  Treat- 
ment.— Support  strength  by  enemata  if  necessary ;  nitric  acid  freely  to 
sloughing  parts  ;  chlorate  of  potash  lotion  to  mouth :  quinine  internally. 

Carbuncle. —  Causes. — Occiu's  chiefly  in  men  over  forty-five.  Diabetes; 
debility ;  {see  also  Boils).  Character. — Inflammation  of  skin,  and  cellular 
tissue  beneath.  May  begin  with  a  small  pustule,  but  essentially  proceeds 
from  a  non-cLrcumscribed  sloughing  of  cellular  tissue.  Brawny,  painful 
swelling  ;  suppuration  ;  formation  of  several  openings  ;  destruction  of  all 
affected  parts  down  to  subjacent  muscles  and  tendons — then  gradual  healing 
and  cicatrization.  Constitutional  disturbance  more  or  less  severe  ;  blood- 
poisoning  ;  sometimes  death  from  pyaemia,  less  frequently  from  exhaus- 
tion. Treatment. — Support  strength  with  tonics  and  good  diet ;  fresh 
air  ;  crucial  incision  (?  ?)  ;  subcutaneous  incision  ;  pressure  by  strapping 
with  plaster ;  caustics  ;  destroy  the  centre  of  the  carbuncle  (about  one- 
fourth  its  area)  by  caustic  potash ;  strong  carbolic  acid.  Paget  recom- 
mends emplastrum  plumbi  on  leather,  with  a  small  hole  in  the  middle, 
for  small  carbuncles,  and  resin  cerate  under  a  poultice  for  larger  ones. 
Danger  of  hemorrhage  when  incisions  are  made. 

Carbuncle,  Facial. — Carbuncle  attacking  face,  especially  Hps,  is  particu- 
larly dangerous.  It  is  so,  probably,  from  causing  phlebitis,  which  extends 
to  the  cerebral  tissues.  There  is  swelling  of  the  cheek  and  nose,  and 
exophthalmia.  Fatal  cases  present  also  symptoms  of  pysemia.  Prompt 
incision,  and  quinine  to  cinchonism  recommended. 

Castration. — Kequired  for  malignant  or  other  hopeless  disease  of  the 
testicle.  Scalpel ;  forceps ;  arterv'-forceps  ;  catgnit  hgature  for  scrotal 
vessels  ;  whipcord  ligature  for  cord  ;  suitable  dressings.  Hold  testicle  in 
left  hand,  so  as  to  tighten  the  scrotum  ;  incise  skin,  etc.,  from  external 
abdominal  ring  to  bottom  of  scrotum,  so  as  to  expose  testicles  ;  pull 
down  the  cord,  and  put  whipcord  ligature  right  round  it.  In  cancer 
cases,  dissect  upward,  and  tie  cord  as  high  up  as  is  safe.  Cut  cord  a  quar- 
ter of  an  inch  below  Hgature  ;  a  touch  or  two  of  knife  then  liberates  testi- 
cle. Prognosis. — Operation  very  safe.  Peritoneal  process  has  been  opened 
in  a  child,  causing  fatal  peritonitis. 

'  Noma  is  a  gangrene  of  the  genitals  of  female  children,  analogous  to  cancrum  oris. 


OQ  CHEST. 

Catheterism. — See  Strictuke  of  the  Ukethea. 

Cellulitis. — See  Erysipelas. 

Cephalhaematoma. — A  blood-extravasation,  caused  in  child-birth. 
Two  kinds :  1,  between  aponeurosis  and  pei-icranium  ;  2,  between  peri- 
cranium and  skull.  Former  is  diifuse :  the  latter  is  circumscribed  and 
small,  and  never  extends  across  a  suture.     Treat  on  general  principles. 

Chancre. — See  Syphilis. 

Cheek,  Congenital  Fissure  of. — Extremely  rare.  Accompanied  by 
imperfect  development  of  external  ear.  Treat  by  methods  used  for  hare- 
Hp. 

Cheloid. — Two  kinds  :  1,  Cheloid  of  Alibert.  A  fibrous  or  fibro-cel- 
lular  outgrowth  from  a  cicatrix,  forming  a  tubercle,  at  fii*st  pink,  after- 
ward whitish.  Tends  to  disappear  spontaneously,  especially  in  youth.' 
Treatment. — Excise  if  hard  and  unsightly,  or  following  puncture  of  the 
lobule  of  the  ear  for  earrings.  Very  liable  to  return.  2.  "True  Cheloid" 
of  Addison.  "Not  a  tumor  at  all ;  but  a  patch  of  hide-botmd  skin,  in 
which  the  skin,  fascia,  and  muscles  are  adherent  together,  and  the  surface 
is  yellowish  and  covered  with  scales  "  (Holmes). 

Chest,  Injuries  of. — Divided  into  (1)  non-penetrating,  (2)  penetrat- 
ing. Wounds  of  the  soft  parts  present  nothing  special.  Rupture  of  the 
pectoral  muscles  sometimes  takes  place,  as,  for  instance,  by  a  falling  man 
catching  at  some  support  in  his  descent.  For  Fractures  of  the  Ribs  and 
Sterniun,  vide  article  Fractuees. 

Chest,  Penetrating  Wounds  of. — These  will  be  noticed,  according  to 
the  pai'ts  injiu-ed,  under  the  following  heads  :  1,  wound  of  pleura ;  2, 
wound  of  lung  ;  3,  hernia  of  lung  ;  4,  wound  of  pericardium  ;  5,  wound 
of  heart;  6,  wounds  of  certain  blood-vessels. 

1.  Wound  of  Pleura. — Rarely  occurs  without  wound  of  lung.  May  pre- 
sent aU  the  local  symptoms  of  wound  of  lung,  except  that  any  air  expelled 
from  the  wound  by  respiration  is  not  churned  up  with  blood  into  fine  froth. 
Such  air  must,  of  course,  have  entered  the  pleural  cavity  from  without  the 
chest.     Treatment. — As  for  wound  of  lung. 

2.  Wound  of  Lung. — Signs. — Escape  of  air  from  wound,  often  churned 
up  with  blood  into  froth  ;  pneumothorax ;  hsemothorax  ;  cough  ;  blood 
and  bloody  froth  coughed  up  ;  emphysema.  After-consequences  (both  of 
this  and  the  preceding  injury). — Pleurisy;  pneumonia;  hydrothorax ; 
empyema.  Prognosis. — Bad,  but  very  far  from  hopeless.  If  a  week  passes 
over,  hope  is  considerable.  Treatment. — Perfect  rest  in  bed  on  injured 
side  ;  strap  chest ;  dress  antiseptically  ;  low  diet ;  give  iced  milk ;  avoid 
stimulants,  even  to  remove  collapse.  Collapse  helps  to  stop  hemorrhage, 
which  is  the  first  great  danger.  If  pulse  rises,  or  inflammation  threatens, 
bleed.     Vide  also  Pneumothorax,  Emphysema,  etc. 

'  See  Clinical  Society's  Transactions,  1880,  p.  61. 


OICATEICES.  57 

# 

3.  Hernia  of  Lung. — Two  kinds  :  1,  primary  ;  2,  consecutive.  Consecu- 
tive comes  on  when  the  wound  has  healed.  Primary  should  be  reduced 
so  long  as  the  lung-tissue  is  healthy  and  uninjured.  Consecutive  can  only 
be  guarded  by  a  shield, 

4.  Wound  of  Pericardium. — Signs. — 1,  A  likely  position  and  direction 
of  wound ;  2,  those  of  hemorrhage  and  shock  ;  3,  those  of  pericarditis, 
viz.,  friction-sound,  extended  duluess  on  percussion,  "thoracic  oppression," 
dyspnoea,  anxiety,  etc.  Pulse  small  and  frequent.  Prognosis. — Not  abso- 
lutely hopeless.  Treatment. — Cold  locally  and  internally ;  perfect  rest  ; 
venesection  ;  digitalis  and  belladonna. 

5.  Wound  of  Heart. — When  death  is  not  instantaneous,  the  above  re- 
marks on  wound  of  pericardium  apply  to  those  of  heart,  only  the  signs 
are  more  severe.  Tremor  of  the  heart  and  disturbance  of  its  action  are 
more  marked.  When  death  is  instantaneous,  patient  either  leaps  up  or 
falls  down,  often  uttering  a  shriek.  A  patient  may  live  for  years,  even 
with  a  foreign  body  in  his  heart. 

6.  Wounds  of  Thoracic  Blood-vessels. — Those  of  aorta  and  vena  cava 
usually  at  once  attended  by  fatal  hemorrhage.  Intercostal  and  internal 
mammary  arteries.  Usually  recommended  not  to  attempt  ligature,  but  to 
trust  to  rest,  cold,  etc.  Vanzetti's  "uncipression."  But  "  Surgical  History 
of  War  of  Rebellion  "  says  that  these  wounds  demand  "  the  rigorous  appli- 
cation of  the  rules  for  the  management  of  wounded  arteries,  the  exposure 
of  the  bleeding  point,  and  a  proximal  and  distal  ligature."  In  wounds  of 
the  chest,  with  lodgement  of  foreign  bodies,  it  can  rarely  be  advisable  to 
make  any  dangerous  search  for  them.  Always  consider  instrument 
wounding,  and  direction  of  wound. 

Chest,  Viscera  Injured  without  External  Wound. — Rare.  Signs,  treat- 
ment, etc.,  may  be  inferred  from  notes  above. 

Chilblains. — Inflammation  of  skin  owing  to  sudden  change  to  or  from 
a  frosty  temperature.  Occurs  usually  in  females  and  children  with  feeble 
circulation.  Congestive  stage  and  ulcerated  or  broken  stage.  Itching. 
Symptoms  aggravated  by  warmth,  dietetic  indulgence,  and  approach  of 
evening.  Treatment. — Regular  and  free  exercise,  fresh  air,  healthy  living, 
well-fitting  boots,  straw  or  cork  "socks"  in  soles  of  boots.  Locally,  in  first 
stage,  stimulating  liniments,  friction  with  snow,  painting  with  iodine,  or 
solution  of  sulphate  of  copper  (gr.  iij.  to  f  ]'.)  In  broken  stage,  use  water- 
dressing  at  first,  afterward  coUodium  flexile  or  Peruvian  balsam.  Small 
doses  of  laudanum,  frequently  repeated,  stimulate  the  capillary  circulation. 

Chloroform. —  Vide  An.s:sthesia. 

Cholecystotomy. — The  gall-bladder  has  been  excised  by  Marion 
Sims ;  result  fatal.  George  Brown  tapped  the  gaU-bladder  success- 
fully. 

Cicatrices. — Liable  to  neuralgia,  contraction,  ulceration,  cheloid,  epi- 
thelial cancers,  besides  other  rarer  affections. 


58  CLUB-FOOT. 

Cicatrices,  Neuralgia  of. — May  arise  from  implication  of  a  nerve,  or 
the  bulbous  end  of  a  nerve  in  a  contracted  cicatrix.  Separate  the  cicatrix 
from  the  parts  beneath,  or,  if  necessary,  excise  the  end  of  the  nerve.  If 
such  a  cause  cannot  be  found,  treat  on  general  principles. 

Cicatrices,  Contraction  of. — Is  a  natural  process,  and  results  from  the 
escape  of  water  from  a  new  scar  as  it  dries  up  and  atrophies  to  ordinary 
connective  tissue  ;  most  frightful  deformities  often  result.  Treatment. — 1, 
Preventive  ;  hasten  healing  of  large  wounds  by  skin-grafting  ;  prevent  con- 
traction during  and  for  some  time  after  cicatrization  by  splints  and  ban- 
dages. 2,  Curative  ;  divide  carefully  the  contracted  bands  ;  keep  the  wound 
stretched  during  recicatrization  ;  graft ;  transplant  large  piece  of  skin  in 
suitable  cases.  When  the  contraction  is  merely  linear,  a  V-shaped  incision 
can  be  made,  and  when  the  tongue  of  skin  thus  formed  retracts  toward  its 
base,  the  two  outer  sides  of  the  V-shaped  wound  should  be  sewn  together 
at  and  near  the  apex  of  the  V.  Pressure  by  strapping  will  weaken  and 
make  thin  a  thick  cicatrix. 

Cicatrices,  Ulceration  of. — Very  Hable  to  occur,  especially  in  lower 
extremities,  and  in  old  and  feeble  people.  Such  cicatrices  should  be  pro- 
tected fx'om  friction  and  damp.  Treatment. — Stimulant  applications  ;  rest ; 
good  living. 

Cicatrices,  Warty  (that  is,  indurated  and  thickened). — ^May  be  blistered 
or  painted  with  iodine.     Do  not  mistake  epithelioma  for  these. 

Cicatrices,  CnELom  of. —  Vide  CnELoro. 

Circumcision. — Done  for  phimosis  in  children  and  for  various  dis- 
eases of  the  prepuce  and  glans  penis  in  adults.  With  the  penis  in  its  nat- 
ural position,  apply  a  pair  of  long-bladed  polypus-forceps  exactly  on  a 
level  with  the  corona  glandis,  but  inchned  sUghtly  forward  rather  than 
perpendicularly  ;  as  the  glans  shps  back,  compress  the  prepuce  with  the 
forceps  ;  then  slice  oif  prepuce  close  to  the  forceps  ;  slit  up  mucous  mem- 
brane with  scissors  right  to  glans  ;  stitch  mucus  flaps  to  skin-flaps  j  check 
hemorrhage.  In  infants,  instead  of  sutures,  merely  wrap  a  piece  of  lint 
round  behind  corona  and  also  over  all  the  parts.  Prognosis. — Fatal  result 
extremely  rare. 

Cirsoid  Aneurism. — See  Aneurism. 

Clitoris,  Hypertrophy  of. — Occasionally  large  size ;  danger  of 
hemorrhage  when  removing  it. 

Club-foot. — Four  types  :  1,  tahpes  varus  ;  2,  talipes  valgus  ;  3,  talipes 
equinus  ;  4,  talipes  calcaneus.  Tahpes  equino-varus  (a  combination  of  1  and 
3)  most  common.  Causes. — The  cause  of  congenital  talipes  varus,  or  equino- 
varus,  is  arrested  development.  At  the  commencement  of  their  development, 
the  lower  extremities  are  so  placed  that,  if  extended,  the  feet  would  point 
backward  ;  hence  they  have  afterward  to  rotate  on  their  axes  ;  when  this  ro- 
tation is  not  fully  accomphshed  m  the  foot,  club-foot  results.  Talipes  valgus 
is  only  another  name  for  flat-foot,  which  results  from  excessive  standing  or 


CLT7B-F00T.  59 

walking  when  the  general  strength  is  small ;  the  muscles,  being  then  weak, 
do  not  sufficiently  assist  the  ligaments,  which  give  way  to  the  strain.  In- 
fantile paralysis  leads  to  equino-vainis,  because  that  is  the  position  in  which 
gravity  places  a  foot  uncontrolled  by  healthy  muscles.  Symptoms. — Pure 
varus. — Very  rare  ;  in  it,  only  inner  border  of  foot  is  raised,  and  anterior 
pai-t  of  foot  is  bent  inward  on  posterior  half.  Equino-varus. — ^In  this,  the 
heel  is  more  or  less  raised  ;  in  severe  cases  the  bones  are  much  altered : 
the  dorsum  of  the  cuboid  and  fifth  metatarsal  bone  sustains  the  weight  of 
the  body.  The  scaphoid  and  inner  edge  of  the  metatarsus  look  upward  ; 
the  inner  malleolus  almost  touches  the  scaphoid,  and  the  astragalus  is 
pushed  outward.  Fibula  hes  in  a  Hue  behind  tibia  ;  tuberosity  of  os 
calcis  looks  upward  ;  in  talipes  calcaneus  the  heel  is  down  and  the  front  of 
the  foot  up.  The  tendons  contracted  in  each  case  will  be  mentioned  under 
the  head  of  treatment.  Course. — If  left  alone,  patient  learns  to  walk  on 
deformed  foot  ;  callosities  form  where  there  is  friction  or  pressure  ;  the 
leg  wastes  ;  the  foot  and  leg  thus  get  the  peculiar  clubbed  appearance. 
Treatment. — Mild  cases  do  not  require  tenotomy  ;  employ  friction,  and 
twist  the  foot  for  a  quarter  of  an  hour  three  times  a  day  into  its  natural 
position,  pulling  and  fixing  foot  in  position  with  strapping ;  strapping 
combined  with  splints  ;  Barwell's  elastic  bands  ;  shoes,  etc.,  for  talij)es. 
The  above  contrivances  used  after  tenotomy.  Tenotomy. — For  equinus, 
divide  tendo  AchiUis  ;  for  equino-varus,  tendo  AchiUis  after  tibialis  posti- 
cus and  anticus  (sometimes  also  plantar  fascia,  and  some  plantar  muscles). 
Valgus  and  calcaneus  seldom  require  tenotomy  [see  Flat -Foot.)  Tenotomy- 
knives,  blunt-pointed  and  shai-p-pointed  ;  pads  of  Hnt ;  hot- water  can  and 
strapping  ;  bandage  ;  splint.  Tendo  AchiUis. — Position,  on  face.  Assistant 
makes  tendon  tense  ;  pass  a  sharp-pointed  knife  beneath  tendon,  one  inch 
from  insertion  ;  place  left  forefinger  over  it ;  cut  gently  with  sawing  motion 
toward  skin  ;  assistant  should  relax  when  he  feels  that  the  tendon  has 
gone  ;  withdraw  knife  and  instantly  place  finger  over  wound  ;  then  put  on 
pad  instead  of  finger,  strap,  bandage  and  splint.  TibiaHs  j)osticus. — One 
inch  above  inner  malleolus.  Inner  edge  of  tibia.  In  fat  infants,  midway 
between  anterior  and  posterior  borders  of  leg.  Insert  sharp  tenotome  half 
an  inch,  so  as  to  open  deep  fascia.  Substitute  blunt  tenotome  ;  •  pass  this 
with  one  surface  toward  tibia,  and  other  toward  tendon.  Assistant  mean- 
while holds  foot  inverted.  Now  foot  is  inverted,  at  same  time  edge  of 
tenotome  is  tiu-ned  to  tendon.  If  blanching  of  foot  and  much  bleeding 
show  wound  of  post-tibial  artery,  merely  pad  and  evenly  bandage  and  con- 
fidently expect  good  result.  But  postpone  instrument  treatment  for  a  fort- 
night. Tibialis  anticus. — Merely  extend  foot,  insert  tenotome,  and  divide 
tendon  from  behind  forward.  Peronei. — Sometimes  divided  for  valgus. 
Divide  behind  external  malleoli  or  a  little  higher ;  adduct  foot.  After-treat- 
ment.— Three  or  four  days  after  tenotomy,  commence  to  extend  by  strap- 
ping, splints,  Scarpa's  shoe,  elastic  bands,  or  some  other  mechanical  con- 


GO  COLOTOMY. 

trivance,  according  to  gravity  of  case.  In  infants,  extension  should  be 
effected  in  a  month.  In  adults,  three  or  four  months  may  be  occupied.  At 
first  the  instrument  should  be  shaped  to  fit  the  deformity ;  never  force  a 
foot  into  an  ill-fitting  instrument ;  attend  daily  to  the  case  ;  beware  of 
pressure-sores  ;  plaster-of-Paris  bandages  may  be  used  instead  of  movable 
apparatus.  Process  of  Healing  in  a  Divided  Tendon. — The  divided  ends  of 
the  tendon  retract,  and  the  neighboring  cellular  tissue  presses  in  between 
them,  filling  the  interspace.  In  this  cellular  tissue  corpuscles  and  lymph 
(inflammatory  new  formation)  are  poured  out,  which  organize  into  fibrous 
tissue,  uniting  and  exactly  resembling  in  structure  the  divided  tendon. 
The  pi'ocess  resembles  that  by  which  the  external  callus  unites  a  fractiu-ed 
bone.  The  advantage  of  tenotomy  is  that  this  new  uniting  medium  is  so 
much  more  extensible  than  the  original  tendon.  Many  surgeons  now  put 
up  the  foot  in  plaster-of-Paris  as  soon  as  the  tendons  have  been  divided  : 
and  Ogston  treats  even  severe  cases  of  club-foot  with  plaster-of-Paris,  and 
without  previous  tenotomy. 

Coccydynia. — A  painful  affection  of  coccyx ;  female  sex ;  generally 
follows  an  injury — this  injury  may  be  received  in  parturition ;  comes  on 
when  coccygeal  muscles  are  put  in  action,  as  by  sneezing,  coughing,  walk- 
ing, defecation,  etc.  Treatment. — If  obstinate,  divide  all  muscular  and 
hgamentous  structures  from  borders  and  tip  of  coccyx. 

Collapse. — See  Shock. 

Colotomy. —  When  Required. — In  obstruction  to  the  large  intestine,  as 
from  stricture  of  rectum  (malignant  or  otherwise),  or  imperforate  anus  ; 
in  diseases  of  rectum  or  colon,  e.g.,  ulceration,  or  recto-vesical  fistula, 
where  it  is  desirable  to  prevent  the  irritation  of  faeces  in  the  diseased 
parts.  Three  operations,  viz.  :  1,  Amussat's  in  right  lumbar  region  ;  2, 
Amussat's  in  left  lumbar  region  ;  Littre's  in  left  groin.  The  left  lumbar 
operation  is  sometimes  named  after  Callisen,  who  merely  attempted,  but 
never  effected,  an  operation.  Amussat's  in  Left  Lumbar  Region. — Scalpel, 
forceps,  retractors,  director,  handled  needles,  etc.  ;  incision  midway  be- 
tween last  rib  and  crest  of  ilium,  transverse  or  obUque,  i.e.,  parallel  to 
nerves;  extent,  5  inches  ;  centre  half  an  inch  posterior  to  middle  point  of 
crest  of  ilium  (Allingham)  ;  outer  edge  of  quadratus  lumborum  thus  ex- 
posed ;  now  divide,  from  quadratus  outward,  on  a  director,  the  muscles  to 
the  extent  of  the  skin  wound  (latissimus  dorsi,  obliquus  externus  and  in- 
ternus,  and  transversalis)  ;  secure  vessels  ;  distinguish,  if  possible,  trans- 
versalis  fascia  from  peritoneum  ;  divide  fascia  ;  find  colon  ;  pass  two  liga- 
tures through  skin  at  both  edges  of  wound,  piercing  colon  on  their  way  ; 
make  opening  in  bowel  big  enough  to  admit  forefinger  ;  puU  out  hoops  of 
Hgatures  and  divide  them,  thus  making  four  ligatures  ;  tie  each.  Oil  mar- 
gins of  wound  and  place  patient  in  bed.  Occasional  difficulty  in  finding 
bowel,  especially  when  there  is  not  complete  obstruction  and  it  is  nearly 
empty.     Use  of  distending  injection  before  operation.     Bowel  must  not  be 


CUT   THROAT.  61 

sought  for  too  far  out  from  spine  ;  always  lies  in  front  of  or  below  kidney. 
Roll  patient  on  his  left  side,  keeping  finger  in  wound,  bowel  will  some- 
times then  fall  upon  finger  ;  not  much  danger  of  wounding  peritoneum  if 
bowel  be  distended.  Much  danger  of  wounding  peritoneum  in  infants,  be- 
cause descending  mesocolon  often  exists.  Operation  in  right  lumbar  re- 
gion done  in  a  similar  manner.  After-treatment — Sedatives  at  first ; 
dress  with  oakum  ;  protect  edges  of  wound  with  zinc  ointment ;  india- 
rubber  bag  and  soft  bandage  afterward  ;  give  good  diet  early  ;  if  opening 
contracts,  use  sponge-tents  ;  lower  part  of  intestine  should,  after  convales- 
cence, be  occasionally  washed  out  with  warm  water.  Prognosis. — Accord- 
ing to  Caesar  Hawkins  two-thirds  recovered.  But  many  more  cases  have 
since  been  recorded,  and  the  fatal  cases  appear  to  die  not  so  much  from 
operation  as  from  original  disease  ;  therefore  operation  should  be  done  in 
time. 

CrcusSn  "  }  °f  Brain.-  Vide  Hea.,  fcomoES  of. 

Condylomata. — Causes. — Mostly  syphilis,  gonorrhoea,  and  dirt.  Path- 
ology.— Papilliform,  but  sarcomatous  or  made  of  soft  connective  tissue  in 
structure  ;  non-recurrent ;  infectious.  Seat. — About  anus,  foreskin,  pre- 
puce, and  mucous  membrane  of  mouth.  Treatment. — Touch  with  argent, 
nit. ;  zinc  oxide,  calomel,  copper  sulphate  ;  cleanliness,  dryness  ;  wear  pre- 
puce back. 

Contusion. — See  Bruise. 

Corns. — Causes. — ^Intermittent  pressure,  or  friction  from  tight  or  over- 
loose  boots.  Pathology.  — At  first  a  thickening  of  cuticle,  then  a  bursa  forms 
beneath  ;  afterward  cuticle  may  grow  thin  while  fibrous  structures  be- 
neath hypertrophy  and  form  base  of  corn,  or  the  pressure  of  the  thickened 
cuticle  may  cause  absorption  of  the  parts  beneath  ;  tendency  to  inflame 
and  suppurate.  Resulting  lameness  may  lead  to  secondary  effects.  Treat- 
ment.— Remove  cause.  Proper  boots.  Acetic  acid,  nitrate  of  silver,  alka- 
line solutions,  soap,  water-dressing,  etc.,  to  soften  cuticle  ;  knife  to  remove 
it.  Open  suppurating  corns.  Soft  corns  [i.e.,  those  which  form  beneath 
the  toes)  may  be  also  cured  by  cotton  wool  between  the  toes,  dusting  with 
zinc  oxide  or  with  French  chalk,  and  by  above  remedies  also.  Boots  should 
be  broad  in  sole,  and  straight  along  inner  border.      Belladonna  plaster. 

Coxalgia. — A  term  for  hip-disease. 

Cut  Throat. — Usually  suicidal.  Position. — Generally  opposite  larjTix, 
which  it  of  course  opens,  unless  the  wound  be  superficial.  Dangers. —  (A, 
immediate)  1,  hemorrhage  ;  2,  suffocation  by  blood-clot ;  3,  suffocation  by 
a  displaced  solid  structure  ;  4,  entrance  of  air  into  a  divided  vein.  (B, 
secondary)  1,  exhaustion  ;  2,  erysipelas ;  3,  abscess ;  4,  some  form  of 
blood-poisoning  ;  5,  bronchitis  or  pneumonia  ;  6,  secondary  hemorrhage, 
especially  such  as  might  be  provoked  by  the  patient  tearing  the  wound 
open  afresh.     (C,  remote)  1,  cicatricial  stenosis ;  2,  fistula.     Prognosis. — 


62  DELIRIUM   TREMENS. 

When  a  large  vessel  is  wounded,  death  is  usually  almost  immediate.  In 
other  cases  the  prognosis  would  be  hopeful,  but  for  the  imfavorable  state 
of  body  and  mind  visually  coexisting  in  suicides.  Treatment. — 1,  Arrest 
hemorrhage ;  tie  bleeding  vessels  ;  2,  extract  clots  from  air-passages ;  3, 
if  the  injured  parts  cannot  be  brought  into  apposition  without  sutures,  and 
if  these  sutvu-es  will  not  interfere  at  all  with  drainage,  use  them.  In  most 
cases  sutures  are  not  necessary  ;  place  a  bandage  round  the  head  and  an- 
other round  the  chest,  and  connect  these  in  such  a  manner  as  to  hold  the 
chin  down  toward  the  chest ;  4,  in  cases  where  the  injury  is  such  as  to 
seriously  obstruct  breathing  through  larynx,  perform  tracheotomy  ;  5, 
dress  the  wound  with  a  mass  of  antiseptic  gauze  (of  course,  this  is  not 
meant  to  keep  the  wound  aseptic)  ;  6,  the  patient  mvist  be  diligently  fed, 
and  if,  fi'om  wound  of  the  oesophagus  or  damage  to  the  larynx,  swallowing 
is  impossible  or  difficult,  a  tube  must  be  passed  down  the  guUet  and  food 
passed  through  it.  Be  sure  not  to  pass  this  tube  into  the  trachea  by  mis- 
take, a  blunder  easily  made  ;  7,  see  that  the  nursing  is  diligent,  energetic, 
and  vigilant. 

Cysts. — See  Ttjmoes. 

Deformities  are  of  many  different  kinds,  and  are  described  elsewhere. 
Vide  articles  Palate,  Cleft  ;  Club-foot  ;  Cicatrices,  Contraction  of  ; 
Joint  Diseases  ;  Paralysis,  Congenital  ;  Spine,  Curvature  of,  etc. 

Delirium  Tremens,  though  usually  arising  directly  from  prolonged 
and  excessive  drinking,  is  not  unfrequently  produced  by  a  wound  or  com- 
pound fracture  acting  as  an  exciting  cause  in  patients  who  have  not  lately 
been  guilty  of  great  excess.  Accessory  causes  are  abstinence  from  food, 
and  any  other  depressing  influence.  Pathology. — "The  striking  appear- 
ance, "pos^-morfe?7i,  "is  that  of  excessive  serosity  "  in  the  ventricles  of  the 
brain  and  between  its  membranes.  Symptoms. — Tremor,  especially  ob- 
servable in  the  hands  and  tongue.  "Wandering  of  the  mind,  usually  limited 
to  delusions  about  certain  things;  e.g.,  the  patient,  while  knowing  per- 
fectly well  where  and  with  whom  he  is,  yet  fancies  there  is  a  demon  or 
some  noxious  animal  in  the  comer  of  the  room,  or  following  him  about 
from  place  to  place.  His  mind  is  ever  recurring  to  these  fancies,  and  he 
frequently  talks  about  them  and  insists  upon  taking  measures  to  escape 
from  his  imaginary  enemies  :  his  delirium  is  a  fussy,  "  busy  "  one.  He  is 
always  in  a  state  of  dread,  and  is  often  inclined  to  suspect  his  friends  of 
harboring  designs  against  him.  In  his  active  anxiety  to  escape  from  these, 
he  may  do  himself  or  even  bystanders  some  injury.  Hands  unsteady. 
Tongue  not  only  tremulous,  but  coated,  usually  with  a  creamy  fur.  Bowels 
confined.  Breath  foul,  frequently  alcoholic.  No  appetite.  Sleeplessness, 
which  has  usually  existed  as  a  premonitory  symptom  before  the  delirium 
sets  in.  Diagnosis. — From  (1)  acute  mania,  (2)  meningitis,  (3)  delirium 
of  fevers.  Note  the  coolness  and  moisture  of  the  skin,  absence  of  fever  and, 
very  likely,  of  pain  in  head.     In  the  continued  fevers,  prostration  has  prob- 


DISLOCATION.  63 

ably  preceded  the  delirium,  but  thermometric  observations  and  a  considera- 
tion of  the  history  (which  is,  unfortunately,  not  always  easy  to  get)  should 
settle  the  diagnosis.  There  is  something  very  characteristic  about  the 
manner  of  the  delmum  in  Delirium  Tremens,  Prognosis.  — If  sleep  can  be 
quickly  procured,  good.  If  not,  and  especially  if  the  tongue  gets  dry  and 
brown,  bad.  Treatment. — Indications  (1)  to  procure  sleep,  (2)  to  keep  up 
the  strength.  Watchful,  firm  and  gentle,  good-natured  nursing.  Milk, 
strong  beef-tea,  and  small  quantities  of  nutritious  solid  food,  if  it  can  be 
borne,  at  frequent  intervals.  Stimulants  should  either  be  forbidden  alto- 
gether, or  else  allowed  only  in  small  quantities  at  a  time,  and  then  only  on 
condition  that  food  be  taken  with  each  draught.  Beer  is  the  best  stimvilant 
in  these  cases.  A  dose  of  calomel  (5-10  grains)  justifiable  at  first.  Mor- 
phia subcutaneously.  Hydrate  of  chloral  (30  grains)  repeated  in  two 
hours,  and  then  in  another  three  houi-s.  DigitaHs  in  large  doses  has  been 
recommended.  Mr.  Holmes's  remarks  on  treatment  of  Delirium  Tremens 
in  his  Treatise  are  very  clear  and  instructive. 

Diabetes,  Traumatic,  has  followed  injury  to  the  brain,  and  then 
sometimes  passed  off  as  the  cerebral  injury  was  recovered  from. 

Diphtheria  is  said  to  attack  wounds  when  a  layer  of  whitish  false 
membrane  forms  on  them  and  is  at  the  same  time  accompanied  by  slough- 
ing.    See  Hospital  Gangbene. 

Dislocation. — Three  kinds  :  1,  traumatic  ;  2,  congenital ;  3,  sponta- 
neous. In  traumatic,  the  capsule  is  almost  always  ruptured.  Complicated 
Dislocations. — In  these  there  is  either  fracture,  or  wound  of  skin,  or  of 
large  vessel,  or  of  nerve,  or  several  of  these  misfortunes. 

Causes  of  dislocations.  — 1.  External  force,  which  is  (a)  direct  or  (6)  in- 
direct. 2.  Muscular  action  {e.g.,  usual  in  dislocation  of  lower  jaw).  Symp- 
toms.— 1.  Altered  form  of  joint.  Compare  two  sides  of  body.  2.  Line  of 
direction  of  misplaced  bone  does  not  pass  through  the  articular  surface  of 
the  other  bone.  3.  Lengthening  or  shortening  of  limb.  4.  Altered  posi- 
tion of  Hmb  to  trunk,  e.g.,  projection  of  elbow  from  side.  5.  Abnormal 
distance  between  certain  prominent  points  of  skeleton,  e.g.,  between  in- 
ternal condyle  and  olecranon.  6.  Ecchymosis  (rarely  distinct  at  first, 
sometimes  absent).  7.  Pain.  8.  Inability  to  move  the  limb.  Manual  ex- 
amination must  finally  settle  the  question  in  most  cases,  showing  the 
articular  cavity  empty  and  the  head  of  the  bone  at  some  other  point. 
Anaesthesia  may  be  necessary  for  a  diagnosis,  because  of  soft  parts  being  so 
swollen  and  tender.  A  soft  crepitation  sometimes  caused  by  rubbing  head 
of  bone  on  torn  capsular  ligaments  and  tendons,  partly  from  the  compres- 
sion of  firm  coagula.  Diagnosis.— 1,  From  dislocated  articular  fracture. 
Easily  made  by  an  attempt  at  reduction.  The  latter  is  readily  reduced, 
but  returns  at  once  ;  2,  from  contusion  and  sprain.  Examine  carefully  ;  3, 
from  relaxation  of  the  capsule  in  paralyzed  limbs.  Here  consider  the 
history,  and  make  a  carefGl  local  examination. 


64  DISLOCATION. 

Capsular  opening  is  of  variable  size.  Escaped  head  of  bone  does  not 
always  remain  immediately  opposite  it.  Occasional  spontaneous  reduction 
by  muscular  action. 

Mechanical  Obstructions  to  Reduction. — 1,  Contraction  of  muscles.  Head 
of  bone  may  be  caught  between  two  contracted  muscles  ;  2  (a  far  more 
frequent  obstacle),  a  small  capsular  opening,  or  its  occlusion  by  the  en- 
trance of  the  soft  parts  ;  3,  certain  tensions  of  the  capsular  or  strengthen- 
ing ligaments.  Reduction. — Easiest  immediately  after  the  injury.  Later, 
ansesthesia  often  required.  Manoeuvres  depend  on  joint  affected.  Usually, 
the  assistants  make  the  motions  while  the  surgeon  himself  manipulates 
head  of  bone.  Often  everything  depends  on  correct  anatomical  knowledge. 
Multiplying  pulleys,  Bloxam's  dislocation  tourniquet :  these  things  now 
only  used  tmder  anaesthesia  ;  when  they  involve  the  apphcation  of  straps 
round  the  chest,  they  make  ansesthesia  more  dangerous.  If  too  great 
violence  is  used — 1,  patient  may  collapse ;  2,  limb  may  mortify  from  the 
pressure  ;  3,  great  vessels  or  nerves  may  be  ruptured  ;  4,  rupture  of  other 
soft  parts,  as  skin  or  muscle  ;  5,  fracture  of  bone  ;  6,  limb  may  be  torn  off. 
These  accidents  occur  mostly  in  attempting  to  reduce  old  dislocations.  The 
results  of  pressirre  best  prevented  by  fastening  the  straps  over  a  wet  band- 
age previously  applied  from  below  upward.  Nerves  and  muscles  are  most 
liable  to  rupture  when  adherent  to  deep  cicatrices.  Use  of  Malgaigne's 
dynamometer  to  measure  force  employed.  After-treatment. — Reduce 
synovial  inflammation,  which  always  ensues,  by  moist  bandages  and  cold 
compresses.  Passive  motion  :  in  shoulder,  not  for  a  fortnight ;  in  elbow 
and  hip,  earlier.     Too  early  motion  may  cause  : 

Habitual  Dislocation. — Wlien  a  joint  has  been  several  times  dislocated, 
it  becomes  extremely  liable  to  dislocation.  Treatment. — Long  rest  of  the 
joint. 

Irkeducible  Dislocation. — Eestore  the  movements  as  far  as  possible  by 
passive  and  active  exercise,  otherwise  the  muscles  atrophy.  The  anatom- 
ical changes  are  as  follows  :  The  extravasation  is  reabsorbed  ;  the  capsule 
folds  together  and  atrophies  ;  the  soft  parts  about  the.  misplaced  head  be- 
come infiltrated  with  plastic  lymph,  and  transform  to  cicatricial,  firm  con- 
nective tissue,  which  partly  ossifies  ;  the  cartilage  metamorphpses  into 
connective  tissue,  and  adheres  to  the  neighboring  parts';  the  surrounding 
muscles  suffer  considerably  from  molecular  disintegration  and  fatty  meta- 
morphosis. How  long  Dislocations  are  Reducible. — Depends  on  joint.  Ball 
and  socket  much  longer  than  hinge-joints.  Shoulder  may  be  reduced  after 
years.  Hip,  even  after  two  or  three  months,  very  difl&cult.  Tenotomy  has 
been  employed,  but  not  very  successfully,  for  the  chief  obstacle  is  the 
firm  adhesion  of  the  head  of  the  bone  in  its  new  position.  Is  reduction 
of  such  old  dislocations  desirable  ?  Often  preferable  to  let  patient  simply 
exercise  limb  well  in  its  new  position.  Breaking  up  adhesions  about  the 
head  of  the  bone  by  rotating  it  forcibly  {vide  Anesthesia)  may  facili- 


DISLOCATION.  65 

tate  this.  Pressure  on  bracliial  plexus  may  require  excision  of  head  of 
humerus. 

Complicated  Dislocations. — 1.  With  fracture.  Always  attend  to  this, 
and  apply  an  apparatus  till  it  has  united,  changing  it  and  putting  the  joint 
in  a  new  position,  say  every  ten  days,  to  prevent  stiffness.  2.  With  com- 
pound fracture.  Eesect  joint,  or  try  to  save  it,  using  some  thoroughly 
antiseptic  method.  If  there  is  considerable  crushing  and  tearing  of  the 
soft  parts,  amputation  may  be  required. 

Congenital  Dislocations. — Distinguish  from  those  caused  during  partu- 
rition. Occur  in  most  of  the  joints  of  the  extremity,  but  especially  in  the 
hip.  Head  of  bone  above  and  behind  acetabulum.  Generally  readily  re- 
placed. Peculiar  wabbling  gait.  If  the  dislocation  is  one-sided,  patient, 
lying  on  his  back,  turns  the  foot  inward.  Acetabulum  is  too  shallow,  and, 
in  adults,  filled  with  fat.  Ligamentum  teres,  if  it  exists,  is  abnormally 
long.  Head  of  femur  too  small.  Articular  cartilage  usually  completely 
formed.  Capsule  very-  large  and  relaxed.  Cure  mostly  impossible.  Causes. 
— Perhaps  excessive  quantity  of  fluid  in  joint,  at  very  early  period  of  uterine 
life.  Perhaps  also  extreme  abduction  in  uterine  life.  Result. — In  course 
of  time,  spinal  curvature.  Treatment. — It  has  been  recommended  that  the 
thigh  should  be  kept  for  a  very  long  time  in  a  position  of  abduction  {see 
lledical  Record,  1880). 

Dislocatio'n  of  Ankle. — Four  directions;  outward,  inward,  backward, 
forward.  1.  Outward. — Accompanied  by  fracture  of  fibula  above  outer 
malleolus  and  rupture  of  deltoid  ligament  or  fracture  of  inner  malleolus. 
Same  thing  as  "  Pott's  Fracture."  Foot  turned  outward.  Depression  over 
fracture  of  fibula.  Treatment. — Dupuytren's  splint  (to  inner  side),  or 
ordinary  leg-splints.  Keep  foot  well  in,  and  sole  at  right  angles  to  leg.  2. 
i?nm?^c?.— Accompanied  by  fracture  of  inner  malleolus.  Treat  on  same 
principle  as  Pott's  Fracture,  only  keeping  foot  well  out.  3  and  4.  Disloca- 
tions backward  and  forward  may  be  distinguished  from  fracture  of  leg- 
bones  by  relation  of  malleoli  to  tarsal  bones.  After  reduction,  apply 
starched  bandages  and  mill-board,  or  some  other  firm  apparatus. 

Compound  Dislocation  op  Ankle-Joint. — Requires  amputation  if  tibial 
arteries  be  injured,  or  other  important  parts  be  much  damaged.  Other- 
wise, remove  small  fragments,  clean,  set  and  dress.  Primary  excision  of 
the  joint  occasionally  advisable.  Ankylosis  pretty  certain.  Use  antisejDtic 
dressing. 

Dislocation  or  Astragalus. — If  simple,  must  be  either  backward  or  for- 
ward. Latter  has  an  inclination  either  outward  or  inward.  Dislocation 
directly  outward  or  inward  is  always  complicated  with  fracture  of  leg- 
bones.  Dislocation  forward  most  common.  Comj)lete  or  incomplete. 
Prominence  of  head  of  bone  beneath  skin  in  front  of  ankle.  Malleolus  of 
side  toward  which  the  bone  is  inclined  projects.  Danger  of  skin  slough- 
ing from  pressure.  Treatment. — Flex  knee  to  relax  gastrocnemii ;  extend 
5 


66  DISLOCATION. 

foot  and  push  astragalus  into  its  place.  This  is  tolerably  easy  in  partial 
dislocation.  But  complete  dislocation  may  require  anaesthesia  and  division 
of  tendo  Achillis.  Dislocation  backward  is  very  rare  and  difficult  to  re- 
duce. Compound  Dislocation. — Except  in  the  most  favorable  cases,  reduction 
is  not  to  be  tried.  The  question  lies  between  excision  and  amputation. 
Decide  and  treat  on  general  principles.  In  simple  irreducible  dislocation, 
primary  excision  is  not  advisable.  The  bone  may  remain  harmless  in  its 
new  place. 

Dislocations  of  Separate  Carpal  Bones,  especially  of  os  magnum,  can  be 
reduced  by  pressure,  and  generally  require,  for  some  time,  apjaaratus  to 
prevent  recun'ence. 

Dislocation  of   Clavicle. — At  the  Sternal  End. — Three  varieties,  viz.  : 

1,  forward  ;  2,  backward ;  3,  upward.  Forward  most  common  ;  others  very 
rare.  The  deformity  is  in  each  case  so  manifest  that  diagnosis  is  palpable. 
In  dislocation  backward,  end  of  clavicle  presses  on  trachea,  oesophagus,  and 
gi'eat  vessels  of  neck.  Treatment. — Extend  shoulders  backward,  and  band- 
age to  a  splint  applied  to  the  back  with  a  pad  between  splint  and  spine. 
Difficulty  of  keeping  bone  in  its  place.  Truss  to  press  on  head  of  bone 
displaced  forward.  At  the  Acromial  End. — Dislocation  almost  always  up- 
ward, but  sometimes  below  acromion,  or  even  below  coracoid  process. 
Reduction  easy  by  j^ulliug  shouldei's  backward.  Here  also  difficult  to  keep 
bone  in  its  place.  Gutta-percha  or  leather  shoulder-cap,  with  a  pad  over 
end  of  clavicle.  Bandage  in  a  line  parallel  to  upper  arm  over  shoulder 
and  elbow.     Then  bandage  ai-m  to  side. 

Dislocation  of  Coccyx  may  result  from  falls  or  during  parturition.  Re- 
duce with  the  assistance  of  a  finger  in  the  rectum. 

Dislocations  of  the  Elbow. — I.  Complete  dislocation  of  radius  and 
ulna :  1,  backward  ;  2,  forward — in  the  former  there  may  be  .fracture  of 
the  coronoid  j^rocess,  in  the  latter  fracture  of  the  olecranon  ;  3,  inward ; 
4,  outward.     The  latter  two  are  rarely  complete. 

n.  Ulna  alone  :  backward  only. 

ni.  Radius  alone :  1,  forward ;  2,  backward ;  3,  outwai'd ;  4,  partial 
foi*ward. 

rV.  Ulna  backward,  with  radius  forward. 

Injuries  of  elbow  often  obscured  by  great  swelling.  Following  ex- 
cellent dil-ections,  as  to  the  points  to  be  noticed  in  an  injury  to  the  elbow, 
are  fi'om  Holmes , (abbreviated) :  1.  Is  there  transverse  fracture  of  humerus  ? 

2.  Longitudinal  or  partial  fractiu'e  of  lower  end  of  humerus  ?  e.g.,  of  con- 
dyle. 3.  Distance  between  olecranon  and  internal  condyle  ?  4.  Fracture 
of  olecranon  ?  5.  Are  motion  and  position  of  head  of  radius  normal  ?  6. 
Do  axes  of  radius  and  ulna  correspond  in  direction  ? 

Dislocation  of  Both  Bones  Backioard. — Prominence  of  olecranon  ;  dis- 
tance between  it  and  internal  condyle  increased.  Prominence  of  lower  end 
of  humerus  below  fold  of  skin  at  front  of  elbow-joint.    (In  fracture  of  lower 


DISLOCATION.  67 

end  of  liumerus,  the  prominence  of  the  upper  fragment  is  above  that  fold.) 
Fractiu'e  of  coronoid  process  causes  increased  mobihty,  as  well  as  crepitus. 

Dislocation  of  both  bones  for icard. — Arm  is  lengthened,  and  olecranon, 
unless  broken  off,  is  on  a  level  with  condyles. 

Dislocation  of  ulna  backward. — Head  of  radius  can  be  felt  normal ;  but 
olecranon  is  too  far  back  from  internal  condyle. 

Dislocation  of  radius  forward  (most  common  of  the  three  modes). — El- 
bow somewhat  flexed,  and  midway  betAveen  pronation  and  supination. 
Further  flexion,  as  well  as  supination,  very  limited  ;  head  of  radius  can  be 
felt  disj)laced.  After  reduction,  veiy  liable  to  recur,  because  orbicular 
ligament  is  ruptured.     Not  uncommon  in  childhood. 

Dislocation  of  radius  backward. — Head  of  bone  can  be  felt  behind  ex- 
ternal condyle. 

Dislocation  outimrd  recognized  by  manipulation. 

Causes. — Falls  upon  elbow  or  hand.     Half  the  cases  occur  in  boys. 

Reduction  of  Dislocations  of  Elbow. — Can  often  be  effected  by  merely 
pressing  the  bones  into  position.  Sometimes  extension,  and  even  anjes- 
thesia,  required.  Dislocations  two  months  old  have  been  reduced,  after 
breaking  down  adhesions  by  forcible  flexion  and  extension.  In  disloca- 
tion of  the  radius,  extend  from  the  hand.  Bending  elbow  across  knee  a 
useful  method  of  reduction.  Compound  Dislocations. — ^Amputation  sel- 
dom necessary. 

Dislocation  of  Head  of  Fibula. — Extremely  rare. 

Dislocations  of  Fingers. — Are  not  common,  and  may  be  reduced  by 
extension.  Amputation  should  never  be  done  for  compound  dislocation, 
unless  the  finger  be  hopelessly  crushed. 

Dislocation  of  Hip. — Four  chief  directions  :  1,  backward  and  upward 
on  dorsum  ilii ;  2,  backward  into  sciatic  notch ;  3,  downward  into  obtura- 
tor foramen ;  4,  inward  on  pubes.  Other  varieties,  e.g.,  into  perineum, 
are  very  rare.  First  form  is  most  frequent.  Causes. — The  backward  dis- 
locations take  place  when  a  person  is  in  a  stooping  position,  and  either 
falls  heavily  on  his  feet,  or  is  struck  by  a  heavy  weight  falling  on  his  back. 
Dislocation  into  the  thyroid  foramen  is  caused  by  sudden  and  violent 
abduction,  and  dislocation  on  the  pubes  by  sudden  and  violent  exten- 
sion of  the  hmb,  esi^ecially  if  coincident  with  a  blow  on  the  back  of  the 
thigh. 

Anatomij. — The  anterior  part  of  the  capsule,  including  Y-ligament  of 
Bigelow,  remains  wholly  or  partially  unruptured  in  all  ordinary  disloca- 
tions, and  thus  limits  the  position  of  the  bone,  interferes  with  reduction 
by  extension,  and  can  be  utilized  in  reduction  by  manipulation.  The  ob- 
turator internus  is  a  strong  tendinous  muscle  ;  and  backward  dislocations 
are  on  the  dorsum  ilii,  or  toward  the  sciatic  notch,  according  as  they  es- 
cape from  the  acetabulum  above  or  below  that  muscle  respectively.  In  the 
lower  dislocation,  the  head  of  the  bone  is  superficial  to  the  obturator  in- 


68  DISLOCATION-. 

ternus.  Fracture  of  the  acetabulum  not  uncommon,  especially  in  dorsal 
dislocation. 

Symjjtoms. — 1.  Dislocation  on  dorsum  ilii.  Hip  looks  widened.  Pecu- 
liar position  of  limb  ;  rotation  inward :  slight  flexion  of  both  hijD  and  knee  ; 
axis  of  thigh  intersects  lower  third  of  sound  thigh  ;  ball  of  great  toe  rests 
on  instep  or  ankle  of  other  foot ;  heel  raised.  Abduction  and  external  ro- 
tation impossible ;  stiffness  and  immobility  under  chloroform  ;  head  of 
bone  makes  a  prominence  in  its  new  position  ;  trochanter  is  above  a  line 
between  ant.  sup.  spine  of  ihum  and  tuberosity  of  ischium  (Nelaton's  line). 
Shorte'niug,  one,  two,  even  three  inches.  2.  Dislocation  in  sciatic  notch. 
— Symptoms  like  those  of  dorsum  ilii  dislocation,  only  less  marked.  Axis 
of  thigh  across  opjposite  knee  ;  ball  of  toe  on  ball  of  other  gi-eat  toe. 
Shortening,  half  to  one  inch.  3.  Dislocation  into  thyroid  foramen. — Body 
bends  forward ;  foot  points  shghtly  outward ;  a  hollowness  takes  the  j)lace 
of  the  trochanter.  Lengthening,  two  inches.  Head  of  femur  perhaps  dis- 
coverable in  its  new  position.  4.  Dislocation  on  pubes. — In  this  and  the 
other  rarer  forms  of  upward  dislocation,  head  of  bone  can  be  felt  in  its  high 
position  ;  flattening  of  hip  ;  abduction  and  eversion.     Shortening  one  inch. 

Diagnosis. — Of  dislocation  on  dorsum  ilii  from  imjjacted  fracture  of 
neck  of  femur  with  inversion.  Under  anaesthetics,  the  former  shows  im- 
mobihty,  the  latter  mobihty.  In  the  former  the  trochanter  is  behind,  in 
the  latter  it  tends  to  He  below  the  ant.  sup.  spine  of  ilium. 

Reduction. — Each  kind  of  hip-dislocation  can  be  reduced  in  two  ways, 
viz.,  extension  and  manipulation.  Extension  method  is  partlj'-  based  on 
the  idea  that  muscular  contraction  is  the  chief  difficulty.  But  it  is  not  so. 
The  main  resistance  proceeds  from  strong  ligaments,  and  sometimes  from 
too  small  a  hole  in  the  capsule.  Hence  the  advantage  of  manipulation. 
Dislocation  on  dorsum  ilii. — 1.  Extension.  Apply  pulleys  just  above  con- 
dyles of  femur,  and  extend  knee  across  lower  third  of  opposite  thigh  ;  fix 
pehis  with  perineal  baud.  2.  Manipulation. — Place  patient  on  back,  and 
give  anaesthetic  completely ;  grasp  knee  and  foot ;  flex  weU  both  knee  and 
hip,  adduct  thigh,  rotate  outward,  and  suddenly  bring  down  the  hmb  into 
a  straight  line  with  body.  If  this  fail,  try  again  and  again,  or  rotate  in- 
ward instead  of  outward.  Dislocation  toward  sciatic  notch. — 1.  Extension. 
Place  patient  on  sound  side ;  apply  perineal  band  and  pulleys  ;  flex  hmb, 
and  draw  it  across  opposite  thigh. — 2.  Manipulation.  Same  proceedings 
as  in  dislocation  on  dorsum  iUi.  Dislocation  into  thyroid  foramen.— 1. 
Extension.  A  pelvic  band  pulls  pelvis  toward  sound  side.  A  perinseal 
band,  working  beneath  it,  is  connected  with  pulleys  which  extend  upward 
and  outward  from  the  injured  hip.  The  sm^geon  grasps  the  ankle  of  the 
dislocated  limb,  and,  dragging  inward,  thus  pries  the  femiu'  into  the 
acetabulum.  Instead  of  the  pelvic  and  perinseal  bands,  the  bed-post  may 
be  placed  in  the  patient's  fork,  and  used  as  a  frJcrum.  2.  Manipulation. 
Flex  hip,  abduct  slightly,  rotate  strongly  inward,  adduct  and  straighten. 


DISLOCATIOIT.  69 

Dislocation  on  pubes. — 1.  Extension.  Extend  limb,  well  abducted,  down- 
ward and  backward  ;  at  same  time  pull  head  of  bone  outward  by  a  towel 
round  thigh  just  beneath  groin.  2.  Manipulation.  Ptdl  strongly  on  thigh 
in  line  of  axis  of  femur,  at  same  time  bending  it  on  the  abdomen  ;  rotate 
inward,  and  bring  down  into  a  line  with  body ;  or  employ  same  manoeu- 
"\Tes  as  in  thyroid  dislocation.  ** 

Old  Dislocations. — Reduction  is  tolerably  safe  to  attempt  up  to  two 
months.     Afterward,  danger  of  inflammation  of  joint  or  fracture  of  femur. 

Dislocation  with  Fracture' of  Femur. — Try  to  push  head  of  bone  into 
place,  or  let  bone  unite,  and  then,  in  sixth  week,  attempt  reduction. 

Dislocation  of  Lowek  Jaw. — Usually  bilateral.  Causes.— Jy'wect  vio- 
lence, or  over-extension  in  gaping.  Symptoms. — Bilateral :  mouth  widely 
open  and  cannot  be  shut ;  saliva  dribbles  ;  speech  and  deglutition  almost 
impossible  ;  depressions  where  condyles  ought  to  be  ;  prominences  behind 
and  beneath  malar  bones.  Unilateral :  symptoms  less  marked ;  chin  in- 
clines toward  sound  side ;  depression  in  front  of  ear  only  on  side  dislo- 
cated. Mechanism. — Two  views.  One,  that  it  is  caiised  by  the  coronoid 
process  locking  against  the  malar  bone ;  the  second  merely  attributes  it 
to  excessive  muscular  action. — Prognosis. — If  left  unreduced,  a  certain 
amount  of  motion  returns,  and  the  teeth  can  be  made  to  nearly,  if  not  quite, 
meet.  Reduction. — Firstly,  disengage  condyle  by  pressing  downward 
with  thumbs,  guarded  by  a  towel,  in  mouth  behind  last  molar  teeth.  Sec- 
ondly, push  chin  backward  and  upward.  Congenital  dislocation  is  gener- 
ally accompanied  by  other  signs  of  imperfect  development.  Subluxation 
is  a  kind  of  "  catching  "  of  the  jaw,  which  the  patient  can  easily  remedy 
for  himself.  It  occurs  in  young  people  of  relaxed  fibre.  General  Treatment. 
— Tonics  and  time. 

Dislocation  of  Knee. — Five  kinds :  forward,  backward,  inward,  out- 
ward, and  dislocation  of  semilunar  cartilage,  called  "subluxation."  The 
first  four  are  unmistakable,  from  the  obvious  deformity.  The  lateral  dis- 
locations are  most  common  and  not  complete.  One  or  other  condyle  slips 
over  to  the  opposite  half  of  the  tibial  surface.  Dislocation  of  the  tibia  for- 
ward is  dangerous  from  pressure  on  pophteal  vessels  by  femur.  Sublux- 
ation is  marked  by  sudden  and  severe  pain  attacking  joint,  which  then 
remains  semiflexed.  Reduction. — Extend  and  rotate  slightly.  Compound? 
dislocation,  except  in  favorable  cases,  requires  amputation.  Subluxation 
is  reduced  by  flexion,  followed  when  the  patient  is  off  his  guard  by  sud- 
den extension,  combined  with  slight  rotation.  While  manipulating,  press 
firmly  with  one  thumb  on  any  tender  spot. 

Dislocation  of  Metacabpal  Bones. — Rare,  obvious,  and  easily  reduced 
by  extension. 

Dislocation  of  Metataesus,  if  compound,  may  require  amputation. 

Dislocation  of  Patella. — Four  kinds :  outward  (most  common),  in- 
ward, edgewise,  and  upward.     Causes. — A  blow  on  the  edge  of  the  pa- 


70  DISLOCATION. 

tella,  or  sudden  muscular  action.  Signs,  etc. — 1,  Outward  (most  com- 
mon) ;  patella  rests  on  outer  side  of  external  condyle,  generally  with  outer 
edge  raised.  2,  Inward  :  most  rare,  almost  unknown.  3,  Edgewise  :  either 
inner  or  outer  edge  of  patella  is  twisted  into  intercondyloid  space,  the 
bone  standing  on  its  edge.  4,  Upward:  ligamentum  patell;i3  is  always 
ruptured  ;  quadricejDS  extensor  pulls  patella  upward.  Reduction. — ^In  first 
two  varieties  flex  thigh  on  abdomen;  press  outer  or  inner  edge  of  j)a- 
tella,  according  as  dislocation  is  outward  or  inward.  The  other  edge  is 
thus  raised  and  the  bone  freed,  the  quadricejDs  at  once  pulling  it  into 
position.  Case  3  often  presents  great  difficulties.  Anaesthesia.  Manip- 
ulation. Manipulation  combined  with  bending  leg  and  rotating  it  on  axis 
of  tibia.  Forcible  flexion.  Sudden  and  violent  extension  made  by  patient 
himself.  The  cause  of  the  difficulty  said  to  be  wedging  of  the  superior 
angle  of  the  bone  in  the  intercondyloid  space.  Shun  any  division  of  ten- 
dons or  ligaments.  If  dislocation  be  irreducible,  wait,  watch,  and  act  ac- 
cording to  the  course  taken  by  nature.  4,  Upward  dislocation  :  treat 
like  fractured  patella. 

Dislocation  of  Lower  Angle  of  Scapula. — Query  as  to  pathology. 
Shipping  of  latissimus  dorsi  or  paralysis  of  serratus  magnus.  On  latter 
supposition  use  strj^chnine  endermically  (Erichsen)  ;  electricity ;'  ortho- 
pedic appliances. 

Dislocation  of  Shoulder-Joint. — Five  kinds :  1,  downward,  sub-cora- 
coid ;  2,  downward,  subglenoid ;  3,  inward,  sub-clavicular ;  4,  back- 
ward, sub-spinous  ;  5,  upward.  Sub-coracoid  is  far  the  most  common, 
sub-sj)inous  very  rare.  Causes. — Predisposing :  the  natural  shallowness 
and  free  movement  of  the  joint,  previous  dislocation,  male  sex,  old  age. 
Exciting  :  falls  on  shoulder,  elbow,  or  hand;  muscular  action.  To  pro- 
duce the  dislocation  backward,  the  elbow  has  to  be  directed  across  chest 
when  falling,  or  else  twisted  inward.  Signs. — Six  common  signs  (Erich- 
sen)  :  1,  flattening  of  shoulder ;  2,  hollow  under  acromion  ;  3,  apparent 
projection  of  this  process,  with  tension  of  the  deltoid ;  4,  presence  of 
head  of  bone  in  an  abnormal  situation;  5,  rigidity;  6,  pain  in  shoulder. 
These  resolve  themselves  into  three  simply :  1,  head  of  bone  is  evidently 
absent  from  its  place  beneath  acromion;  2,  it  is  present  elsewhere;  3, 
there  are  such  sigcs  as  are  common  to  dislocation  of  all  joints,  viz.,  stiff- 
ness, pain,  etc. 

1.  Sub-coracoid. — ^Head  of  bone  under  or  slightly  internal  to  coracoid 
process.  To  feel  it,  raise  the  elbow.  Elbow  projects  fi*om  side.  Slight 
lengthening,  real  or  apparent,  of  upper  arm;  rarely  slight  shortening. 
Stiffness  ;  movement  only  possible  antero-posterioiiy. 

2.  Sub-glenoid. — ^IVIuch  like  sub-coracoid,  but  head  of  bone  more  dis- 
tinctly felt  in  axilla,  elbow  projects  more,  and  there  is  lengthening,  one 
inch.     Marked  symptoms  of  pressure  on  axillary  vessels  and  nerves. 

3.  Sub-clavicular. — An   extreme   degree    of    "sub-coracoid."      Promi- 


DISLOCATION.  71 

nence  of  liead  of  bone  beneath  clavicle.     Elbow  projects  backward  and 
outward. 

4.  Subspinous. — Head  of  bone  felt  beneath  spine  of  scapula.  Elbow 
outward  and  forward. 

5.  Vpiuard: — Always  complicated  with  fracture  of  acromion  or  cora- 
coid.  Consequently,  injury  and  swelling  likely  to  be  severe.  Shortening. 
Crepitus  and  deformity. 

Anatomy. — In  the  first  three  forms  the  inner  and  lower  part  of  the 
capsule  is  torn,  and,  if  the  disjDlacement  be  great,  either  the  great  tuber- 
osity of  the  humerus,  or  else  some  of  the  muscles  attached  to  it  (supra- 
and  infra-spinatus  and  teres  minor)  have  to  give  way.  In  sub-glenoid, 
the  sub-scapularis  also  goes.  In  sub-sjDinous,  also,  the  sub-scapularis  is 
torn.  In  sub-spinous,  head  of  bone  lies  between  sub-scapularis  and  teres 
minor  ;  in  sub-glenoid,  between  sub-scapularis  and  long  head  of  triceps  ;  in 
sub -clavicular,  on  second  and  third  ribs. 

Diagnosis. — 1.  From  fracture  of  neck  of  humerus.  This  fracture  is 
never  caused  by  anything  but  direct  violence.  Then  there  are  the  general 
differences  between  fracture  and  dislocation.  Both  injuries  may  occur 
together.  2.  From  mere  paralysis  of  deltoid.  Then,  although  there  is 
flattening,  still  head  of  bone  is  easily  felt  in  glenoid  cavity. 

Reduction. — By  heel  in  axilla;  by  manipulation;  by  pulleys;  by  knee 
in  axilla;  by  air-pad  in  axilla;  by  extension  upward.  Heel  in  Axilla. — 
Patient  lies  on  back.  Surgeon  sits  with  unbooted  heel  in  injured  axilla. 
Extension  made  either  by  himself,  or  by  assistants  or  pulleys.  Anaesthesia. 
Slight  rotation  of  limb  facilitates.  Neither  anesthesia  nor  assistants 
necessary  in  most  cases,  llanijndafion. — Bring  arm  with  a  sweep  round 
in  front  of  chest  and  face,  then  rotate  inward  whilst  bringing  the  arm 
down  to  the  side  again.  This  should  be  done  by  one  hand  of  the  surgeon, 
while  with  the  other  he  tries  to  press  the  head  of  the  humerus  into  its 
place.  Anesthesia  helps.  Pulleys. — Anaesthesia.  Caution :  danger  of 
rupturing  nerves,  axillary  artery,  etc.  Forearm  has  been  torn  off.  First 
apply  a  wet  bandage  to  the  arm,  then  put  on  a  clove-hitch  over  the  band- 
age, above  the  elbow.  Extension  should  be  slow  and  patient.  Counter- 
extension  by  a  jack-towel,  or  by  surgeon's  heel  or  knee.  Knee  in  Axilla. — 
Patient  sits  on  a  chair.  Surgeon  places  one  foot  on  chair  and  the  knee  in 
axilla.  He  then  seizes  the  arm,  extends  a  short  time,  and,  lastly,  steadying 
the  shoulder  with  left  hand,  uses  the  knee  as  a  fulcrum  on  which  to  lift 
humerus  into  its  place.  Or,  as  recommended  by  Flower  in  Holmes's 
system,  the  surgeon  can  place  his  back  against  a  door-post  and  have  exten- 
sion made  through  the  doorway  by  assistants,  while  he  steadies  the  shoul- 
der with  both  hands.  Mr.  Cock  placed  an  air-pad  in  the  axilla  and  bound 
the  elbow  firmly  to  the  side.  In  tliree  days  the  dislocation  was  found  to 
be  reduced.  All  other  attempts  had  previously  failed.  Extension  upward 
can  also  be  made  with  the  heel  against  the  shoulder  ;  or  extension  outward 


72  DISSECTION    WOUNDS. 

with  counter-extension  from  opposite  wrist.  Skey  has  shown  that,  owing 
to  the  great  mobility  of  the  scapula,  the  real  direction  of  the  extending 
force  is  much  the  same,  whatever  it  may  be  apparently. 

Compound  Dislocation  of  Shoulder. — Rarity.  Question  of  resection  un- 
certain. Antiseptic  treatment.  Complications. — 1,  With  fracture  of  neck 
of  humerus  attempt  reduction  by  manipulation,  then  treat  fracture.  If  re- 
duction impossible,  put  up  fracture,  and  in  sixth  week  (when  union  has 
taken  place)  again  attempt  reduction.  If  rupture  of  axillary  artery  occur, 
reduce  dislocation  first,  and  then  tie  both  ends. 

Dislocation  of  Thumb  (Metacaepo-Phalangk\l  Joint). — Almost  always 
backward.  Signs. — Thumb  is  bent  back.  Head  of  metacarpal  can  be  felt 
projecting  on  palmar  aspect,  and  base  of  first  phalanx  on  dorsal  aspect. 
Main  obstacle  to  reduction  is  engagement  of  neck  of  metacarpal  between 
two  heads  of  flexor  brevis  pollicis,  as  in  a  button-hole.  Reduction. — The 
efforts  are  directed  to  disengage  from  flexor  brevis  pollicis ;  bend  the 
metacarpal  joint  of  the  thumb  well  into  palm  of  the  hand,  thus  relaxing 
the  muscle  ;  now  press  the  first  phalanx  of  the  thumb  well  backward,  i.e., 
hyperextend  it ;  at  the  same  time  pull  the  thumb  downward,  i.e.,  toward 
the  tijDs  of  the  fingers  ;  lastly,  flex  the  thumb  (every  joint)  into  the  palm  : 
if  this  fails,  the  pulleys  may  be  tried.  Anaesthesia  ;  subcutaneous  division 
of  one  or  both  heads  of  flexor  brevis,  or  lateral  ligaments  ;  passing  a  blunt 
hook  through  a  small  incision  and  hooking  tendons  of  flexor  brevis  over 
head  of  metacarpal  bone.  After  reduction,  keep  thumb  bent  toward  palm 
for  a  day  or  two. 

Dislocation  of  Wrist. — Extremely  rare  ;  readily  reduced.  Diagnosis. — 
From  CoUes's  fracture  ;  in  fracture  the  styloid  processes  go  with  the  hand  ; 
in  dislocation,  they  approach  too  near  the  finger- clefts. 

Dissection  Wounds. — Under  this  head  we  notice  the  lymphatic  and 
cellular  inflammations  and  blood-poisoning  produced  by  absorption  of  ani- 
mal poison  fi'om  dead  bodies.  Bodies  lately  dead  much  more  dangerous 
than  those  which  have  been  long  dead  ;  bodies  dead  from  erysipelas,  peri- 
tonitis, puerperal  and  tj'phoid  fevers  especially  dangerous.  Peritoneal 
fluid  particularly  poisonous  after  death  fi'om  peritonitis.  Not  necessary 
that  there  should  be  a  skin  wound.  Poison  absorbable  through  hair-fol- 
licles or  through  unbroken  skin.  Signs  and  Prognosis.— Three  grades  of 
severity  :  in  the  first  the  symptoms,  except  shght  fever  for  a  few  days,  are 
trivial  and  almost  confined  to  the  limb  poisoned  ;  in  the  second,  there  is 
either  severe  cellulitis  in  the  limb,  or  abscesses  form  in  parts  of  the  body 
beyond  the  limb,  or  both  these  troubles  may  be  present.  This  grade  is 
liable  to  pass  into  chronic  pyaemia.  The  third  grade  is  marked  by  violent 
and  sudden  symptoms  of  septicaemia,  and  often  terminates  fatally  in  two  or 
three  days.  The  point  of  inoculation  usually  looks  angiy  and  purulent, 
and  ]5resents  either  a  vesicle,  a  pustule,  or  a  scab  ;  it  is  painful ;  the  lym- 
phatics extending  from  it  to  the  nearest  glands  are  reddened,  tender,  and 


DYSPHAGIA.  73 

sometimes  surrounded  by  inflamed  and  even  suppurating  cellular  tissue 
(phlegmonous  erysipelas) ;  these  glands  are  tender  and  enlarged,  and 
abscesses  tend  to  form  around  them.  Chills,  rise  of  temperature,  and  other 
feverish  symptoms  come  on  within  twenty-four  houi's.  Symptoms  such  as 
these  are  common  to  almost  every  case,  but  the  further  coiu'se  is  variable. 
In  the  third  grade  of  cases,  within  forty-eight  hoiu's,  to  quote  IMr.  Callender, 
"the  patient,  flushed,  anxious,  restless,  even  delirious,  is  in  a  hopeless 
condition,  with  prostration  and  rapid  sinking."  In  the  second  gi'ade, 
there  may  be  extensive  cellulitis  or  the  formation  of  numerous  abscesses 
near  glands ;  but  so  long  as  the  disease  is  subacute  or  chronic,  and 
provided  actual  pysemia  does  not  occur,  the  prognosis  is  very  hopeful.  In 
these  cases  the  spirits  are  usually  very  low.  In  the  first  grade,  recoveiy 
takes  place  in  a  week  or  two,  or  even  in  a  few  days.  Ti-eatment. — If,  while 
dissecting,  the  hand  should  be  wounded,  grasp  it  so  as  toj<;heck  the  return 
of  venous  blood,  wash  it,  suck  the  wound,  permit  it  to  bleed  freely,  and  let 
a  stream  of  cold  water  flow  over  it.  If  afterward  signs  of  local  poisoning 
appear,  give  the  Umb  complete  rest,  and  the  patient  a  country  holiday,  with 
instructions  to  avoid  any  kind  of  exertion,  for  excitement  of  the  cii'ulcation 
apppears  to  drive  poison  from  the  wound  inward.  Cauterize  the  wound  ;  a 
warm  bath  for  the  limb  ;  generous  diet ;  fresh  air  ;  tonics  ;  purgatives  ;  rest 
in  bed  for  the  severe  cases  ;  to  properly  rest  a  limb,  splints  are  necessary ; 
mill-board  and  starch  apparatus  ;  poultices.     Open  abscesses  as  they  form- 

DroAArning. — See  article  Asphyxia. 

Dura  Mater,  Fungus  of. — A  tumor  springing  fi-om  the  dura  mater, 
and  pressing  outward  through  the  cranium  ;  simple  and  malignant  forms ; 
the  thin  skull  may  be  felt  crackUng  over  the  tumor  after  it  has  pressed  its 
way  through,  and  the  tumor  pulsates  with  the  respiratory  movements  Hke 
the  brain.  Before  tumor  appears  externally,  there  are  usually  signs  of  in- 
tracranial pressure,  e.g.,  diploj)ia  or  even  convulsions.  Prognosis. — Eventu- 
ally fatal,  without  treatment ;  very  unpromising  with.  Treatment. — Moderate 
compression  gave  relief  in  some  cases.  In  suitable  cases  expose  tumor  by 
a  cinicial  incision  ;  enlarge  opening  in  skull,  if  necessary,  with  trephine,  and 
remove  tumor  from  dura  mater,  if  possible.  It  is  next  to  impossible  to 
diagnose,  before  operating,  whether  similar  tumors  spring  from  the  dura 
mater  or  from  the  cranium  itself.  Refer  to  Louis  on  Fimgous  Tumors  of 
Dura  Mater,  "  Sydenham  Society's  Translation." 

Dura  Mater,  Irritation  of. — Injuries  of  the  head  which  cause  this  pro- 
duce symptoms  such  as  contractures  and  convulsions  on  the  same  side  of 
the  body. — See  Duret  on  "  Cerebral  Traumatism,"  and  an  abstract  by 
Ferrier,  in  Brain  for  1879.  A  very  severe  case  of  this  affection  recovered 
under  cold  douche. — See  "Transactions  Clinical  Society,"  1879,  p.  145. 

Dysphagia  is  a  symptom  arising  from  obstruction  to  the  oesophagus, 
e.g.,  by  pressure  from  aneurism,  tumors,  etc.,  or  from  ulcers,  cancers,  or 
foreign  bodies ;  sometimes  merely  spasmodic.      Vide  CEsophagus. 


74  ELEPHANTIASIS    ARABUM. 

Eczema. — A  superficial  inflammation  of  the  skin,  with  a  tendency  to 
spread,  and  attended  by  the  formation  of  minute  vesicles,  from  which 
escapes  a  discharge,  usually  serous.  Three  varieties :  1,  eczema  simplex, 
or  ordinary  eczema ;  2,  eczema  impetiginodes,  where  the  secretion  is  puru- 
lent ;  3,  eczema  rubrum,  where  there  is  great  redness  and  inflammation. 
Eczema  squamosum  is  a  term  applied  when  the  transudation  dries  quickly. 
Causes. — Three  classes:  1,  dii-ect  ii'ritants,  e.g.,  solar  and  tropical  heat,  the 
water  cure,  mercvuial  inunction,  irritation  of  parasites  ;  2,  venous  obstruc- 
tion, e.g.,  varicose  veins  in  legs  ;  3,  constitutional  causes  ;  sometimes  con- 
genital ;  occasional  connection  vnth.  dyspepsia  and  disordered  menstruation. 
Scrofulous  and  rickety  children  are  much  disposed  to  eczema.  Gout. 
SymjJtovis  and  Course. — Skin  red  and  moist,  the  moisture  exuding  from 
minute  vesicles.  Or,  instead  of  moisture,  a  branny  dryness.  Itching. 
Tendency  to  become  chronic  and  to  recur.  Prognosis. — As  a  rule,  quite 
amenable  to  treatment.  T^'eatment.-^JJng.  hydrarg.  ammoniat. ;  lotion  of 
hydrarg.  perchlor.  (gr.  ij.  ad  3  j.)  ;  ung.  zinci.  Scabs  to  be  removed  by 
fomenting  and  poulticing,  or  by  soaking  in  oil ;  lotions  of  carbonate  of 
soda  to  check  dischai-ge.  For  very  extensive  eczema  with  great  itching, 
use  the  shower-bath  two  or  three  times  a  day  for  ten  or  fifteen  minutes  in 
a  warm  room.  For  old  cases  with  thickening  of  the  skin,  soft-soap,  tar, 
and  caustic  potash  may  be  used  ;  rub  the  soft-soap  in  twice  a  day  with 
flannel,  for  three  days,  then  stop,  leaving  the  soap  on  for  three  more  days, 
then  remove  the  soap  by  a  bath.  A  few  days  after  this,  commence  a 
similar  course  again,  and  repeat  till  a  thorough  ciu-e  is  efi:ected.  .  'WTien 
the  eruption  is  dry  and  scaly,  use  tar  ointment.  Danger  of  tar-poisoning 
(known  by  diarrhoea,  vomiting,  tarry  odor  of  urine  and  vomit).  When 
soft-soap  and  tar  are  well  borne,  but  do  not  cure,  ajDply  caustic  jDotash 
(  3  j.  aquse  3  ij.)  once  a  week  ;  immediately  afterward  apply  cold  wet  com- 
presses to  relieve  the  violent  pain.  Constitutional  treatment  often  advis- 
able. Laxatives,  arsenic,  Donovan's  solution,  iodide  of  potassium  in 
increasing  doses.  Vigorous  local  treatment  should  not  be  employed  in  moist 
eczema  of  the  face  or  scalp  of  childi-en,  or  when  the  eczema  appears  to  be 
vicarious  for  other  diseases.  The  probable  cause  should  never  be  neglected. 
In  eczema  of  the  legs  from  varicose  veins,  prescribe  horizontal  rest  in  mid- 
dle of  day,  and  support  from  rubber  bandages  or  elastic  stockings.  Always 
superintend  the  use  of  these  bandages  at  first. 

Elephantiasis  Arabum. — Causes  unknown.  Occui's  in  hot  coun- 
tries, especially  West  Indies  and  South  America  ;  rare  in  Europe.  Synip- 
toms. — Great  hypertrophy  of  skin  and  subcutaneous  areolar  tissue  of  some 
part  of  the  body.  Parts  usually  affected  are  lower  extremities,  scrotum, 
labia,  and  face.  Pathology. — It  appears  to  depend  on  obstruction  of  the 
lymphatics  and  lymphatic  glands.  The  arteries  of  the  part  are  usually 
much  enlarged.  Treatment. — Ligature  of  the  main  artery' of  the  limb  has 
cured  some  cases,  but  failed  in  others. 


EPISTAXIS. 


75 


Elephantiasis  of  Scrotum. —  Vide  Scrotum,  Diseases  of. 

Embolism. — Signifies  the  conveyance  of  some  solid  body,  small  or 
large,  by  the  cm-rent  in  a  blood-vessel,  tiU  it  stops  and  obstructs  some  ves- 
sel ;  this  obstructed  vessel  may  be  an  artery,  or  a  vein,  or  a  capillary,  and 
it  may  be  in  the  systemic  or  the  pulmonic  circulation.  The  obstructing 
body  is  called  an  embolus,  and  is  usually  a  i^iece  of  fibrin  washed  from  one 
of  the  cardiac  valves,  or  from  the  clot  in  an  aneui'ism,  or  from  an  inflamed 
vein.  "Where  the  embolus  rests  an  abscess  is  apt  to  form.  In  regions 
where  the  collateral  circulation  is  poor,  e.g.,  in  the  brain,  death  of  the 
parts  whose  blood-supj^ly  is  obstructed  by  the  embolus  may  occm-.  When 
emboli  are  of  a  septic  nature,  they  produce  pya^mic  abscesses.  Entozoa 
have  been  known  to  constitute  the  emboli. 

Emphysema. — In  surgery,  means  only  the  passage  of  air  into  the 
ceUular  tissue.  Causes. — Mostly  wounds  of  lung,  esj)ecially  by  broken  ribs. 
Very  rarely  decomposition  and  consequent  production  of  gas  in  a  wound. 
The  air  almost  always  passes  first  into  the  jDleui-al  cavity,  and  is  pumped 
thence  by  respiratory  movements  into  cellular  tissue.  Symptoms  and  Course. 
— The  pecular  crackling  feeling  is  unmistakable  and  pathognomonic.  Un- 
less the  air  continues  to  pass  into  the  cellular  tissue,  it  is  soon  entirely 
absorbed.  The  emphysema  is  first  noticed  near  the  wound,  and  spreads 
thence  often  to  great  distances.  The  ruptm-e  of  an  air-ceU  in  the  lung 
may  cause  emphysema  of  the  mediastina  and  the  neck.  Treatment. — Treat 
the  cause  ;  put  a  pad  over  the  wound. 

Empyema. — Fluid,  at  first  serum  or  blood,  effased  in  the  plem-al 
cavity,  may  become  jDiu-ulent.  The  condition  thus  produced  is  called  an 
empyema,  and  is  described  more  fully  in  medical  than  in  surgical  works. 
But  I  must  call  attention  to  the  treatment  by  excision  of  part  of  a  rib. — 
(Peitavy  :  Medical  Record,  Aug.,  1876  ;  W.  Thomas :  Birmingham  Medical 
Review.) 

Enchondroma. — See  Tumoes. 

Epistaxis. — Bleeding  from  the  nose.  Causes. — Congestion  of  mucous 
membrane  of  nose  ;  this  may  result  from  catarrh,  from  a  varicose  condi- 
tion of  the  nasal  veins,  the  result  of  old  catarrh,  from  congestion  of  the 
liver,  from  heart  disease,  and  even  from  dyspepsia.  Childhood  and  pu- 
berty are  the  usual  ages,  but  middle  life  (from  hver,  heart,  or  kidney  dis- 
ease, etc.)  is  also  subject.  Epistaxis  in  old  age  sometimes  appears  to  result 
from  weakness,  which  it  of  course  aggravates.  Blows  ;  hemorrhagic  dia- 
thesis ;  vicarious  menstruation.  Pror/nosis.^Dangerousin  old  and  weakly 
people.  Treatment. — Perfect  rest,  coolness,  but  extremities  should  be 
warm  ;  bathmg  face  with  hot  water  to  diminish  congestion  of  mucous 
membrane  ;  sometimes  cold  water  acts  better  ;  raising  hands  above  head  ; 
head  not  to  be  held  down  over  a  basin  ;  injections  of  cold  water,  of  hot 
water  (temperature  100°),  of  tinct.  ferri  perchlor.,  pure  or  diluted  ;  these 
injections  may  be  given  by  a  syringe  which  directs  the  current  backward. 


76  ERYSIPELAS. 

Ice  to  the  back  of  tlie  head ;  cold  to  the  spine  ;  dry  cupping  between 
shoulders ;  plugging ;  plugging  posterior  nares.  Ojieration. — A  piece  of 
whip-cord  is  passed  through  the  nose  into  the  pharynx  by  means  either  of 
Belloeq's  sound  or  of  an  elastic  catheter.  It  is  then  pulled  from  the  phar- 
ynx into  the  mouth  by  forceps,  and  a  plug  of  compressed  sponge  or  lint 
tied  to  that  part  of  the  string  now  hanging  out  of  mouth,  but  some  dis- 
tance from  its  end.  Plug  should  be  small  and  nicely  shaped,  or  part  of 
it  wiU  irritate  back  of  phaiynx  or  even  top  of  larynx.  Now  ptdl  the  string 
back  thi'ough  the  nose  and  guide  the  plug  into  the  posterior  nares.  Nasal 
and  oral  ends  of  string  should  be  tied  together  and  fixed  on  face  with 
strapping.  "When  removed,  plug  is  to  be  pulled  back  through  mouth ;  but 
string  should  not  be  taken  away  till  danger  of  recurrence  seems  to  be  gone. 

Epithelioma. — See  Cancer. 

Epulis. — A  term  applied  to  fibrous,  sarcomatous,  and  cancerous  tu- 
mors of  the  gums.  Most  are  fibro-myeloid  ;  the  less  of  the  myeloid  struc- 
ture, the  more  innocent  the  growth.  Symptoms. — Non-cancerous  epulis  ; 
a  fleshy  red  tumor  of  the  gum  ;  teeth  loosened  and  pushed  forward  ;  size 
variable  ;  sometimes  ulceration.  Cancerous  epuHs  has  the  special  marks 
of  malignancy,  rapid  growth,  excavated  ulcer,  etc.  Prognosis. — Neither 
fibrous  nor  myeloid  epulis  usually  returns  if  the  bone  from  which  it  springs 
be  removed.  Treatment. — Eemoval  of  tumor  and  attached  alveoli  with 
cutting  phers  and  smaU  saw. 

Erysipelas. — A  diffuse  inflammation  of  the  skin  or  subcutaneous  areo- 
lar tissue,  or  of  both  together,  almost  always  attacking  the  neighborhood 
of  some  wound.  Three  kinds,  viz.  :  1,  simple ;  2,  cellulo-cutaneous  ;  3, 
diffuse  ceUiilitis.  Causes. — Usually  a  wound  which  has  been  exposed  to 
unhealthy  influences,  e.g.,  septic  vii-us,  draughts  of  cold  air,  constant  mech- 
anical irritation,  certain  epidemic  influences,  contagion  from  an  adjacent 
case  of  erysipelas  or  puerperal  fever.  Predisposing  causes  are  bad  ven- 
tilation, bad  and  insufficient  food,  dysjpepsia,  hospital  air  when  impure, 
depressed  nervous  system,  want  of  cleanhness,  diabetes,  kidney  disease, 
alcoholism,  contact  of  atmospheric  germs  with  a  wound.  Signs. — 1.  Sni- 
PLE  Erysipelas.  At  first,  rigors,  fever,  sudden  rise  of  temperatiu-e,  some- 
times to  104°,  symptoms  of  disordered  digestive  organs,  e.g.,  furred 
tongue,  constij)ation,  or  diai-rhoea.  In  about  twenty-four  hours,  some- 
times later,  a  rosy  redness  appears  on  the  tract  of  skin  afi'ected.  Margins 
of  redness  either  well-  or  ill-defined.  It  disappears  on  pressure.  Slight 
superficial  swelling  ;  when  the  face  or  head  are  affected  there  is  often  con- 
siderable oedema,  especially  of  eyelids.  Progress  of  fever  is  irregular,  and 
depends  on  whether  rash  spreads  or  not.  Recovery  usually  takes  place  in 
mild  cases  in  a  few  days,  in  more  severe  cases  in  a  week  or  so,  and  is  fol- 
lowed by  desquamation.  Often  the  adjacent  lymphatic  glands  enlarge  be- 
fore the  erysipelas  appears.  The  rash  may  spread  all  over  the  body  (ei-y- 
sipelas  ambulans),   or   disappear  in  one   place   to  reappear   in   another 


excisiojS"  of  joints.  77 

(erysipelas  erraticum).     These  varieties  are  more  serious.     When  there  is 
a  wound,  it  ceases  to  secrete  healthy  pus  for  a  time.     Pain  is  rarely  severe. 

2.  Ckllulo-cutaneous  Erysipelas  (Phlegmonous  erysipelas). — Constitu- 
tional symptoms  are  as  in  simple  erysipelas,  but  more  severe.  Eedness 
deeper.  Swelling  greater.  Within  a  week  the  swelling  becomes  boggy, 
and  next  fluctuates,  indicating  suj)puration.  Throbbing  pain  and  perhaps 
a  sHght  subsidence  of  the  symptoms  may  x^i'ecede  suppuration.  Extensive 
sloughing  usually  occurs. 

3.  Diffuse  Cei^lulitis  is  always  preceded  by  a  wound,  esj)ecially  a  dis- 
secting-wound  or  the  bite  of  some  venomous  animal.  The  skin  is  not 
much  affected;  but  the  subcutaneous  cellular  tissue  presents  the  same 
oedema,  swelling,  hardness,  bogginess,  fluctuation,  suppuration,  and  slough- 
ing as  are  seen  in  phlegmonous  erysipelas.  The  constitutional  symptoms 
are  severe  and  usually  of  an  asthenic  type.     Danger  of  pyaemia. 

Pathology. — All  the  above  forms  are  related,  and  are  primarily  inflamma- 
tions of  the  lymphatics  (lymphangitis),  erysipelas  simplex  affecting  only 
the  cutaneous  absorbents.  In  the  boggy  stage  of  cellulitis  and  phleg- 
monous erysipelas,  the  cellular  tissue  is  distended  with  eflusion,  and  parts 
of  it  are  approaching  a  state  of  mortification.  Sloughing  and  suppuration 
almost  always  follow.  Great  thickening  and  stiffness  are  often  left  after 
the  deeper  varieties  of  erysipelas.  Diagnosis. — Do  not  confoun.d  the  red- 
ness and  oedema  over  an  abscess  beneath  deep  fascia  with  erysipelas. 
Diagnose  also  ivom.  phlebitis.  Prognosis. — Bad  when  the  habits  are  intem- 
perate, kidney  or  liver  diseased,  age  old  or  very  young,  cause  ejDidemic, 
form  erratic  or  recurrent,  duration  prolonged,  or  if  very  severe  and  occur- 
ing  in  the  head  and  face  (or  neck  especially).  Treatment. — Commence 
Mdth  purge  (calomel  gr.  v.-x.),  salines,  tinct.  ferri perchlor.  (fTl,.  xx.  4"^  horis). 
Diet  nourishing,  but  light ;  avoid  loading  with  more  food  than  is  digested. 
Stimulants  recommended  by  most  authorities.  Moderate  tempei'ature, 
fresL  air,  but  no  draughts.  OiDium  not  well  borne.  Local  treatment  in 
simple  erysipelas,  cotton-wool,  flour,  zinc  oxide,  especially  for  erj'sipelas 
intertrigo,  that  is  the  form  caused  by  two  moist  cutaneous  surfaces  rubbing 
against  each  other.  Caustics,  circumscribing  lings  of  argent,  nit.  or  tinct. 
iodine  of  very  doubtful  benefit.  In  the  deeper  varieties  of  erysipelas,  fluc- 
tuating spots  should  be  opened,  and  tense  parts  marked  with  smaU  incisions 
(2  inches),  before  they  fluctuate.  Poultices.  If  incisions  cause  hemor- 
rhage, stuff  with  di-y  or  oiled  lint.  At  commencement  of  eiysipelas  in 
strong,  otherwise  healthy  persons,  with  foul  tongues,  give  an  emetic.  This 
sometimes  aborts  the  attack.     Elevate  position  of  part  affected. 

Excision  of  Joints. — The  indications  for  excision  and  the  conditions 
of  success  vary  with  each  joint.  Objects  of  excision  may  be  :  1,  to  merely 
expedite  recovery  ;  2,  to  restore  motion  to  an  anchylosed  joint ;  or  3,  one 
of  the  various  purposes  for  which  amputation  is  done.  Hence  the  choice 
often  lies  between  excision  and  amput3,tion. 


78  EXCISION    OF   JOINTS. 

CoiiPAEisoN  OF  Excision  and  Amputation. — Life  is  always  to  be  consid- 
ered before  limb.  Excision  involves  a  larger  wound  and  greater  strain  on 
the  constitution :  hence  it  is  bad  for  tuberculous  and  cachectic  people. 
Much  depends  on  the  particular  joint.  Excision  safer  than  amputation  at 
shoulder  and  hip.  Danger  equal  for  the  two  operations  at  the  elbow  ;  at 
knee,  excision  is  far  more  dangerous  than  amputation.  At  elbow  and  wrist 
excision  is,  of  course,  far  preferable  to  amputation,  because  it  leaves  the 
hand.  At  knee,  amputation  is  generally  to  be  preferred,  because  of  the 
great  danger  of  excision.  Excision  of  ankle  is  often  a  good  operation  ;  but, 
if  the  tarsal  bones  are  diseased,  there  is  great  danger  of  recurrence,  and 
removal  of  too  much  bone  would  leave  too  weak  a  foot.  Operation. — In- 
struments :  knives,  forcej)s,  lion-forceps,  saws  (Butcher's  saw,  key-hole  saw, 
chain-saw,  etc.),  chisels,  cutting-pliers,  rasping  instruments  for  scraping 
off  periosteum,  retractors,  directors,  excision  director.  Esmarch's  bandage 
generally  to  be  used.  The  following  six  directions  are  abbreviated  from 
Erichsen  :  1,  Make  incisions  sufficiently  free,  and  parallel  to  important 
parts,  so  as  not  to  divide  them  ;  2,  economize  length  of  bone  by  use  of 
gouge  ;  3,  leave  epiphyseal  cartilage  in  children  ;  4,  do  not  open  medullary 
canal  in  adults  ;  5,  keep  periosteum  ;  6,  do  not  confound  new  bone  or  bone 
softened  by  inflammation,  but  otherwise  healthy,  with  diseased  bone,  etc. 

Process  of  Repair  after  Excision. — This  is  entirely  analogous  to  the 
process  of  repair  after  compound  fi'actures. 

Special  Excisions. 

Ankle- Joint,  Excision  of. — Disease  should  be  limited  to  ends  of  leg- 
bones  and  to  astragalus.  Operation. — Incisions  two  :  one  internal,  along 
edge  of  inner  malleolus ;  the  other,  external,  along  posterior  border  of 
lower. two  inches  of  fibula,  around  outer  malleolus  and  as  far  forward  on 
outer  side  of  foot  as  within  one  inch  of  base  of  fifth  metatarsal  bone.  Saw 
and  nip  off  inner  malleolus  through  inner  incision.  Dissect  soft  parts  suf- 
ficiently away,  puUingperonei  tendons  backward  and  downward,  and  keep- 
ing close  to  bone  to  avoid  posterior  tibial  arterj^  Cut  off  outer  malleolus  ; 
push  tibia  out  of  external  wound,  and  saw  off  its  articular  sui'face.  Next 
remove  part  or  whole  of  astragalus,  according  to  its  condition.  Dress  the 
wound  and  place  the  limb  on  a  firm  splint.  Result. — Generally  good. 
Often  a  movable  joint.  Fatality  1  in  5|-,  success  greatest  when  disease  is 
of  traumatic  origin. 

Elbow,  Excision  of. — In  this  joint,  excision,  if  practicable,  always  pre- 
ferred to  amputation.  A  matter  of  opinion  whether  in  mere  suppurative, 
synovial  disease,  the  results  of  excision  or  of  natural  cure  are  the  best ; 
but  in  necrosis,  excision  should  be  done.  Operation. — Use  a  strong  knife 
and  ordinary  saw.  Longitudinal  incision  5  inches  long,  right  down  to 
bone,  with  its  centre  opposite  inner  border  of  olecranon.  Then  with 
scalpel  separate  soft  parts  from  bones,  proceeding  carefully  between  ole- 
cranon and  internal  condyle,  and  guarding  ulnar  nerve  with  nail  of  left 


EXCISION    OF    JOINTS.  79 

thumb.  Divide  lateral  ligaments,  push  end  of  humerus  out  of  wound  and 
saw  it  off  freely.  Then  project  ulna  and  radius,  grasp  olecranon  with  lion- 
forceps,  and  saw  both  bones  at  level  of  neck  of  radius.  Sometimes  orbic- 
ular ligament  can  be  preserved  with  advantage.  Some  do  whole  operation 
subperiosteally  with  aid  of  rasps.  Subperiosteal  resection  of  doubtful  ad- 
vantage. Results. — In  good  cases,  a  strong  joint  with  all  its  natural  move- 
ments. After-treatment.—'HxQ.QQik  splint.  One  contrived  to  permit  supina- 
tion and  pronation  useful.  In  a  week's  time,  flex  the  elbow  to  a  right 
angle.     When  wound  is  nearly  healed,  use  passive  motions. 

Hip- Joint,  Excision  of. — Indications  for  operation.  See  Disease  of  Hip- 
Joint  and  Gunshot  Wounds.  Operation. — Incision,  free  semilunar  with 
convexity  backward  over  posterior  border  of  great  trochanter  and  down 
to  bone.  Follow  neck  of  bone  to  head,  open  capsule,  and  let  assistant, 
by  adducting,  rotating  inward  and  pushing  upward,  project  head  of  femur 
out  of  wound,  Ligamentum  teres  may  have  to  be  divided.  Joint  very 
rarely  found  dislocated.  If  femur  be  diseased,  saw  below  trochanter. 
Chain- saw  useful.  If  acetabulum  only  be  diseased,  saw  through  neck  of 
femur  and  gouge  acetabulum,  or  cut  it  with  pliers.  Pelvic  fascia  thor- 
oughly separates  acetabulum  from  pelvis.  Acetabular  disease  requires 
freer  incisions.  After-treatment. — Plaster  apparatus  ;  long  splints  with 
iron  interruption ;  mere  extension  by  weight  and  pulley  ;  Sayre's  wire 
breeches.  In  dressing  the  wound  a  stretcher,  with  a  hole  opposite  the  hip, 
like  that  of  Mr.  Croft,  is  useful.  For  heavy  adults  a  stretcher  contrived 
to  slip  easily ,  piecemeal,  under  the  patient,  and  to  leave  the  hips  exposed, 
is  very  useful.  The  stretcher  being  slipped  under  the  patient,  is  lifted  up 
and  i^laced  with  its  two  ends  on  two  chairs  beside  the  bed.  A  dressing- 
pan  being  placed  on  the  floor,  the  wound  can  be  syringed,  if  necessary, 
and  dressed ;  while,  in  the  meantime,  the  bed-sheets  are  changed  or 
smoothed.  Prognosis. — Many  cases  die,  but  probably  not  one-third  of 
these  perish  actually  from  the  operation.  Without  interference  some  of 
the  successful  cases  would  have  perished  of  the  original  disease. 

Knee,  Excision  of. — Indications,  See  Disease  of  Knee- Joint. — Amputa- 
tion almost  always  preferred  for  injury.  Oj^eration. — Nearly  transverse  in- 
cision below  patella  from  back  of  one  condyle  to  back  of  other,  and  divid- 
ing ligamentum  patellpe.  Throw  up  soft  parts  from  patella  and  front  of 
lower  end  of  femur.  Divide  lateral  ligaments  on  the  condyles.  Eetract 
soft  parts  and  project  femur.  Saw  through  condyles  below  the  epiphyseal 
cartilage  in  children.  Proceed  very  carefully,  both  in  separating  soft  parts 
from  back  of  condyles  and  in  making  the  last  cuts  with  the  saw,  or  popli- 
teal artery  may  be  wounded.  Now  push  end  of  tibia  upward  and  forward, 
and  saw  it  off  close  to  articular  surface  in  case  of  children.  Make  saw- 
cuts  through  the  two  bones  so  to  correspond  that  limb  may  be  straight. 
If  they  do  not  fit  in  this  way  after  first  sections,  other  sections  must  be 
made.     Carefully  secure  all  bleeding  vessels.     After  treatment. — Put  ap- 


80  EXCISION    01^  JOINTS. 

paratus  on  at  once.  Some  fixed  contrivance,  like  P.  H.  Watson's  combina- 
tion of  anterior  iron  splint  with  paraffine  or  plaster-of-Paris  bandage,  is 
the  best.  Iron  back-sj)liut  with  foot-piece  and  interrupted  side-splint. 
Bavarian  splint.  Salter's  swing.  Packard's  splint.'  Do  not  distui-b  limb 
for  first  few  days.  Kecovery  and  repair  are  very  slow,  average  eight 
months.  Some  surgeons  leave  patella.  Ankylosis  should  be  osseous.  An 
outwai'd  bend  of  the  Hmb  is  a  common  misfortune  after  this  excision. 

Excision  of  Os  C.vlcis. — Lines  of  incision  :  1,  Along  upper  border  of 
OS  calcis  fi-om  inner  side  of  tendo  Achilhs  to  a  little  in  front  of  calcaneo- 
cuboid articulation  ;  this  should  divide  the  tendo  Achillis.  2.  Across  sole 
of  foot,  from  anterior  end  of  first  incision.  Disarticulate  from  cuboid 
first,  and  from  astragalus  afterward.  Beware  of  wounding  posterior  tibial 
vessels.     A  very  useful  foot  results.     F7^ognosis  is  excellent. 

Excision  of  Scapula. — Done  for  necrosis,  caries,  and  morbid  growth. 
Partial  or  entke.  Crucial  or  T-shaped  incision.  Hemorrhage  occasionally 
very  serious.  In  removing  the  entire  bone,  divide  the  muscles  attached  to 
I)osterior  border  at  an  early  stage  of  the  operation,  and  leave  the  subscap- 
idai-  vessels  till  last.  Tie  the  vessels  as  the  operation  jDroceeds.  Prognosis. 
— Danger  not  so  great  as  might  be  expected. 

Excision  of  Shoulder.— Done  for  gunshot  woimds  and  compoimd  dis- 
locations, and  occasionally  may  be  justifiable  in  cases  of  bone  disease  or 
innocent  tumor.  But,  in  cases  of  bone  disease,  the  cure  by  natural  anky- 
losis affords  a  perfectly  satisfactory  result,  which  is  not  imj)roved  upon  by 
excision.  Operation. — Incision.  Longitudinal  from  just  outside  coracoid 
process  downward  and  outward  for  five  inches,  right  down  to  bone.  Open 
capsule  and  divide  muscles  attached  to  tubercles  of  humerus,  rotating  out- 
ward while  cutting  internal  rotator  (subscapularis),  and  vice  versa.  Arm 
should  at  same  time  be  brought  across  chest.  Pull  tendon  of  biceps  aside. 
Operator  himself  now  seizes  upper  arm  in  his  left  hand  and  pushes  head  of 
humerus  out  of  wound.  Clean  soft  j)arts  from  line  of  saw-cut.  Saw.  If, 
upon  opening  the  joint,  amputation  is  judged  expedient,  make  a  circular 
incision  at  the  lower  end  of  the  longitudinal  one,  and  disarticulate.  Ex- 
cision may  b.e  performed  with  a  flap-incision,  raising  the  deltoid.  Glenoid 
cavity  rarely  removed.  Prognosis. — Veiy  good.  Useful  limb.  Fatality  : 
of  fifty  cases,  in  seventeen  the  glenoid  cavity  was  interfered  with,  and  in 
thirt^^-three  the  head  of  the  humerus  only  was  touched  ;  of  the  seventeen, 
seven  died ;  of  the  thirty-three,  only  one  died.  But  in  military  surgery, 
one  in  four  died. 

Excision  of  Tarsal  Bones. — See  Excision  of  Os  Calcis,  above.  Excision  of 
these  bones  for  disease  requires  a  little  knowledge  of  anatomy,  and  then 
the  surgeon  had  best  be  left  to  adapt  his  incisions  to  the  particular  case. 
The  astragalus  may  be  removed  very  well  by  incisions  similar  to  those 

'  See  Medical  Record,  74,  approved  by  P.  H.  Hamilton  and  L.  A.  Sayre. 


EXOSTOSIS.  81 

given  for  excision  of  the  ankle-joint.  Its  excision  gives  excellent  results. 
Excision  of  the  smaller  tarsal  bones  is  often  by  no  means  a  good  substitute 
for  amputation. 

Excision  of  Wrist. — Lister's  method.  Its  description  includes  at  least 
twelve  directions,  besides  the  aj)plication  of  Esmarch's  bandage.  1.  Make 
first  incision  (two  are  required)  from  dorsum  of  base  of  second  metacarpal 
bone  upward  as  far  as  base  of  styloid  process  of  radius,  always  internal  to 
extensor  secundi  internodii  pollicis.  2.  On  the  thumb  side  of  this  incision 
separate  the  soft  parts  from  the  bones,  carefully  because  of  radial  artery. 
At  the  same  time  divide  the  extensor  carpi  radialis  brevior.  3.  Sever 
trapezium  from  I'est  of  carpus  with  cutting-j)liers.  4.  Clean  soft  parts  from 
bones  on  tdnar  side  of  incision.  5.  Make  ulnar  incision  near  anterior  edge 
of  ulna,  and  extending  from  two  inches  above  styloid  process  to  middle  of 
fifth  metacarj)al  bone.  6.  Raise  all  the  soft  tissues  completely  from  the 
dorsal  surface  of  the  carpus ;  then,  of  com'se,  the  two  wounds  communi- 
cate. In  doing  this  the  extensor  carpi  ulnaris  should  be  severed  from  its 
insertion.  7.  Clean  anterior  aspect  of  carpus  and  ulna,  cutting  off  pisiform 
bone  and  hook  of  unciform  bone,  so  as  to  leave  them  attached  to  the  soft 
l^arts.  Do  not  go  so  far  forward  as  to  w^ound  deep  palmar  arch.  8.  Divide 
ligaments  and  remove  carpal  bones  (except  trapezium)  with  forceps.  9. 
Clean  and  saw  off  ends  of.  ulna  and  radius.  All  cartilage  of  radio- ulnar 
joint  should  be  removed.  10.  Cut  oft*  bases  of  metacarpals  so  far  as  they 
are  covered  with  cartilage.  11.  Take  away  trapezium  and  base  of  first 
metacarpal  bone.  12.  Cut  off  cartilage  of  pisiform  and  leave  the  rest,  and 
the  hook  of  the  unciform,  imless  they  be  diseased.  The  operation  may  be 
shortly  summed  up  thus  :  The  whole  carjius,  except  the  pisiform  and  the 
hook  of  the  unciform,  and  also  the  adjacent  cartilage-covered  parts  of  the 
radius,  ulna,  and  metacarpal  bones,  are  removed  piece  by  j)iece,  in  the  or- 
der found  most  convenient,  through  two  longitudinal  incisions,  one  ulnar 
and  palmar,  the  other  dorsal  and  radial.  Residt. — Very  useful  hand.  After- 
treatment. — Very  important.  Large  lump  of  cork  under  palm  of  hand. 
Flat  wood  palmar  splint.  Regular  passive  motion  from  the  first.  En- 
couragement to  active  motion. 

Exostosis. — Two  kinds  of  true  exostosis,  and  two  allied  bony  growths. 
True  exostosis  is  either  (1)  spongy  or  (2)  ivory.  The  allied  osseous 
growths  are  the  "exercise-bones,"  and  other  ossifications  of  tendons  and 
muscles,  besides  the  "  diffused  osseous  tumor."  Causes. — Usually  unknown. 
Begin  in  youth,  rarely  after  thirty  ;  male  sex.  Pathology.  — Si:)ongj  ex- 
ostosis consists  of  cancellous  bone  covered  with  a  thin  layer  of  hyaline  car- 
tilage. The  cartilage  grows  on  its  superficial  surface,  and  keeps  ossifying 
on  its  deep  sui-face.  Ivory  exostosis  has  the  structui-e  of  compact  bone, 
bat  the  Haversian  canals  are  smaller,  and  the  lacuna?  less  regular.  Growth 
slow,  and  tends  to  stop,  eventually,  even  without  treatment.  Seat.~S})ongy 
exostosis  ;  epiphyses  of  tibia,  fibula,  humerus,  and  femur,  etc.  Ivory  ex- 
6 


82  EXTRAVASATION    OF    URINE. 

ostosis :  bones  of  face  and  skull,  pelvis,  scapula,  and  ungual  phalanx  of 
great  toe.  Characters  and  Symptoms. — They  are  recognized  by  their  hard 
bony  feel,  their  immobility  and  their  jposition.  The.  ivory  exostosis  is  es- 
pecially round,  nodulated,  and  smooth.  The  neck  of  the  tumor  varies  in 
size,  and  this  is  an  important  point  in  treating  hard  exostosis.  They  often 
cause  aching  and  pain  in  the  limb,  and  may  be  serious  from  pressiu'e  on 
important  parts.  Treatment. — They  should  be  let  alone,  unless  they  cause 
great  deformity  or  pain,  or  press  upon  important  parts.  For  they  often 
are  dangerously  near  to  joints,  may  even  be  covered  by  a  pouch  from  the 
articvilai-  synovial  membrane ;  and  the  hard  exostoses  of  the  skull  some- 
times require  great  violence  to  remove  them.  An  incision  should  be  made 
over  the  exostosis  to  be  removed,  and  then  saw,  chisel,  or  cutting-pliers 
apphed.  It  is  said  that  the  neck  need  not  be  removed.  But  Stanley 
■ui-ites  :  "  Absolute  secui'ity  against  the  reproduction  of  an  exostosis  can 
be  obtained  only  by  the  removal  of  every  part  of  its  circumference."  If 
necessary,  he  adds,  the  potassa  fusa  or  nitric  acid  may  be  used  to  produce 
exfoliation  of  the  base  of  the  tumor.  Diffuse  bony  tumor  vavij  requii-e  am- 
putation of  a  limb  or  extirpation  of  an  entire  bone,  and  even  then  it  has 
been  known  to  recur.     Nothing  can  be  done  for  "  exei'cise-bones." 

Extravasation  of  Urine. — When  extravasation  of  urine  is  described 
'as  a  distinct  disease,  it  usually  means  that  which  is  caused  by  the  ui-ethra 
bursting  just  behind  a  stricture.  Kupture  of  the  ui-ethra  from  violence 
causes  similar  symptoms.  Extravasation  into  the  pelvis,  or  into  the  peri- 
toneal cavity,  may  result  from  ruj)ture  of  the  bladder,  quod  vide.  Symp- 
toms.— Patient  has  a  stricture  of  the  urethra  with  retention.  Sudden  sen- 
sation of  relief  and,  simultaneously,  of  something  giving  way  in  perinseum, 
succeeded  by  stinging,  biirning  pain  in  the  part.  Then  swelling  succes- 
sively of  perinseum,  scrotum,  penis,  and  hypogastrium.  Pain  ;  fever,  which 
soon  assumes  a  low  or  "  typhoid  "  character.  Skin  of  parts  affected  dusky 
red  or  purple.  Rapid  sloughing  wherever  the  extravasated  urine  finds  its 
way.  CEdema,  emphysema.  The  retention  itself  is  sometimes  relieved  by 
this  accident.  Prognosis. — In  some  cases  the  mine  again  begins  to  flow 
by  the  vu-ethra,  further  extravasation  ceases,  abscesses  form,  and  the 
sloughs  are  cast  off— the  patient  recovering.  But  it  is  generally  considered 
that,  in  most  cases,  operative  interference  is  urgently  demanded.  Then 
there  is  stiU  great  danger,  first,  from  the  acute  gangrene,  etc.,  and,  lastly, 
fi'om  the  prolonged  suppm-ation  which  ensues.  The  whole  of  both  testicles 
may  be  denuded  by  the  sloughing  ;  but,  if  patient  sui-vive,  the  skin  will 
heal  and  contract  over  them.  Anatomy. — It  is  almost  always  the  bulbous 
part  of  the  urethra  which  gives  way.  Then  the  attachment  of  the  deep 
layer  of  the  superficial  fascia  to  the  posterior  border  of  the  triangular  liga- 
ment, to  the  rami  and  body  of  the  pubes,  and  to  Poupart's  ligaments,  pre- 
vents any  passage  of  the  urine  into  the  thighs,  ischio-rectal  fossae,  pelvis, 
or  buttocks.     Treatment. — Indications  :  1,  to  relieve   the   original   reten- 


FEVEE.  83 

tion  ;  2,  to  give  veut  to  the  slouglis  and  extravasation  ;  3,  to  support  the 
strength.  To  reheve  the  retention,  a  catheter  should  be  passed,  if  j)ossi- 
Lie,  and  left  in.  Th#  retention  is  sometimes  relief ed  by  the  free  incision 
which  should  be  made  in  the  perinaeum,  to  give  vent  to  the  urine  and 
sloughs.  This  free  incision  should  always  be  made.  In  making  it,  place 
the  left  forefinger  in  the  rectum,  to  protect  that  structure,  and  cut  up- 
ward in  the  median  line  in  the  direction  of  the  urethra.  If  the  extravasa- 
tion is  considerable,  other  incisions  should  be  made.  Over  the  incisions 
place  a  poultice,  sprinkled  with  some  antiseptic.  To  keep  up  the  strength, 
give  abundant  nourishment,  tonics,  and  stimulants. 

Face,  Wounds  of.— Readily  heal.  Greatest  care  should  be  taken  to 
prevent  deformities.  Replace  even  hopeless-looking  flaps  ;  hare-lip  pins ; 
horse-hair  sutures.  Removal  of  pins  and  sutures  early,  lest  they  them- 
selves should  cause  scars. 

Fever,  Hectic.  —  The  fever  which  results  from  and  accompanies 
chronic  diseases  of  an  exhausting  character.  Causes. — Any  chronic  sup- 
purative disease,  especially  abscesses  connected  with  bone-€isease  which 
have  opened  externally.  Empyemata,  chronic  suppuration  of  mucous 
tracts,  of  compound  fractures,  or  of  diseased  joints,  etc.  Pathology.— Proh- 
ably  owing  to  the  absorption  into  the  blood  of  the  products  of  inflamma- 
tion or  disintegration.  Symptoms. — Remittent  or  intermittent  daily. 
Temperatui'8  rises  toward  afternoon  or  evening  ;  red  circumscribed  flush 
on  cheeks  ;  tongue  dry  ;  skin  dry  and  hot ;  eyes  bright ;  slight  excitement 
and  sleeplessness.  This  stage  is  followed  nightly  by  profuse  sweats  ;  to- 
ward morning  jDatient  falls  asleep  ;  on  awaking  he  is  still  bathed  in  ]per- 
spiration,  but  with  the  fever  and  high  temperatui-e  either  wholly  or  com- 
paratively passed  away.  In  the  afternoon  the  same  round  of  symptoms 
recommences.  In  the  later  stages  of  hectic,  the  "  colliquative  "  sweats,  as 
they  are  called,  get  more  and  more  profuse  and  exhausting,  and  the  fever 
often  recurs  twice  a  day  ;  the  mouth  becomes  aphthous  and  the  legs  oede- 
matous.  Mental  state  usually  clear  throughout ;  range  of  temperature 
generally  between  99°  and  102°  ;  diarrhoea  is  common.  Prognosis. — De- 
pends on  the  cause.  Treatment. — If  possible,  remove  cause,  e.(/.,  chisel 
out  carious  bone  ;  make  large  abscess  aseptic  ;  give  abundant  nourish- 
ment, but  do  not  overpower  the  digestion  ;  quinine  in  5-grain  doses  ;  sul- 
l^huric  acid,  iron,  opium,  strychnine,  astringents ;  give  opium  cautiously  ; 
its  use  is  to  reheve  any  coincident  j)ain.  Elevate  the  oedematous  legs  ; 
flannel  bandages  carefully  applied  to  these  limbs  ;  astringents  for  the 
diarrhoea. 

Fever,  Inflammatoet  (or  Surgical). — The  fever  which  usually  accom- 
panies inflammations  and  injuries.  No  line  can  be  marked  out  as  separat- 
ing this  fever  from  septicaemia ;  the  two  conditions  pass  imperceptibly  into 
one  another  ;  in  applying  either  name  to  a  given  case,  one  considers 
whether  the  symptoms  and  facts  point  to  the  raised  temperature,  or  to  au 


84  FRACTURES. 

absorj)tion  of  septic  material  as  being  the  chief  direct  cause  of  the  phenom- 
ena which  the  case  presents.  Causes  and  Pathology. — 1,  The  blood  being 
simply  heated  by  passing  thi'ough  an  inflamed  and  consequently  heated 
j)art ;  2,  the  blood  being  poisoned  by  absorption  of  some  product  of  in- 
flammation, whether  decomposed  or  not.  All  the  symptoms  of  inflamma- 
tory fever  and  of  its  ally,  septicaemia,  can  be  produced  by  injection  of  pus, 
putrid  liquids,  SH",  etc.,  into  the  blood  or  cellular  tissue  of  animals. 
Symptoms. — Usually  within  forty-eight  houi-s,  almost  always  within  seven 
days  of  an  injuiy,  the  following  symptoms  may  appear  :  increase  of  heat, 
subjective,  and  evident  also  to  the  thermometer,  frequent  j)ulse,'  chilliness 
or  rigors,  furred  tongue,  sleeplessness,  excitement,  even  slight  deliiium  ; 
urine  high-colored,  deposits  urates ;  increased  urea  ;  bowels  confined. 
The  fever  usually  lasts  a  week.  Persistence  beyond  a  week  denotes  some 
complication,  e.g.,  abscess  or  erysipelas.  If  a  comphcation  cause  the  symp- 
toms to  recur  after  once  disappearing,  we  have  "  secondary  fever."  Prog- 
nosis.— No  danger  from  the  traiimatic  fever  itself,  provided  comjohcations 
do  not  hai^p^.  In  children,  latent  tuberculosis  readily  awakened  by  sur- 
gical fever  (Paget).  Treatment. — See  the  treatment  of  wounds  and  the  pro- 
phylaxis of  septicaemia.     Sahne  refi-eshing  drinks,  fi-esh  ah',  quiet,  rest,  etc. 

Fistula. — See  AitAn  Fistula,  LACHRviviAii  Fistula,  etc. 

Flat-foot. — Causes. — Prolonged  standing  or  excessive  walking  in  per- 
sons of  weak  and  relaxed  fibre,  synovitis  of  ankle,  injury  to  ankle,  gonor- 
rhoeal  rheumatism  of  ankle,  genu  valgum.  Pathology. — The  ligaments 
which  brace  up  the  arch  of  the  instej)  are  lengthened,  the  head  of  the  as- 
tragalus sinks  through  relaxation  of  the  calcaneo-scaphoid  ligament,  and 
the  scaphoid  tuberosity  projects  excessively  ;  in  bad  cases  the  metatarsus 
is  turned  more  or  less  outward,  and  the  other  edge  of  the  foot  turned  up- 
ward by  the  peronei  ;  ankle  bends  inward,  hence  the  name  talipes  valgus. 
Treatment.— ^ieel  spring  or  india-rubber  padimder  arch  of  foot,  the  former 
being  let  into  sole  of  boot ;  internal  upright  bar  to  support  inner  ankle  ; 
bad  cases  of  talij)es  valgus  require  a  horizontal  bar  for  the  attachment  of 
straps  to  correct  abduction  of  metatarsus.  Even  division  of  peronei  oc- 
casionally required.  Always  strengthen  general  health  ;  avoid  standing ; 
and  exercise  systematically  flexor  muscles.  Mr.  Willett  and  myself  have 
succeeded  in  nine  cases  out  of  ten  at  least,  merely  by  judicious  exercise  of 
the  leg-muscles  (Evans's  plan)  combined  with  an  india-rubber  bandage 
properly  apphed  to  the  instep  and  ankle. 

Perforating  Ulcer  of  Foot. — Usually  begins  beneath  a  corn,  tends  to 
perforate  to  dorsum  of  foot,  is  often  attended  by  j)eculiar  afiection  of  the 
nerves  of  the  foot  diseased,  and  is  sometimes  so  difficult  to  cirre  as  to  lead 
to  amputation.     Treat  on  general  principles.      Vide  Ulcer  and  Sinus. 

Fracture,  Varieties.  —  The  main  peculiarities  of  fractm-es  are  ex- 
pressed by  the  terms  complete,  incomplete,  simple,  compound,  impacted. 
Complete  fractures  classified  into  transverse,  oblique,  longitudinal,  dentate, 


FRACTUKES.  85 

multiple,  and  comminuted.  Incomplete  include  ^sswre,  infraction,  splinter- 
ing, perforation.  The  usual  name  for  infi'action  is  green-stick  fractui-e. 
Lastly  may  be  added  separation  of  an  epiphysis.  Causes. — Predisposing : 
1,  an  exposed  situation,  e.g.,  that  of  ossa  nasi ;  2,  bones  of  right  side  break 
oftener  than  those  of  left ;  3,  rough  occupations  of  male  sex  ;  4,  adult  age 
— bones  of  children  are  soft  and  less  brittle  ;  5,  rickets ;  6,  osteomalacia ; 
7,  absorption  of  part  of  thickness  of  bone  by  ulceration  or  abscess  or  tumor. 
Exciting  causes  are  either :  1,  direct,  or  2,  indirect  violence,  or  3,  muscu- 
lar action.  Symptoms. — 1,  Pain  ;  2,  swelling  ;  3,  ecchymosis  ;  4,  crack  felt 
or  heard  by  patient  when  fracture  occurs  ;  5,  abnormal  mobility ;  6,  dis- 
placement ;  7,  crepitus;  8,  loss  of  ftmction  ("paralysis")  of  the  limb  ;  9, 
injury  to  neighboring  soft  parts,  e.g.,  compression  of  braiu  by  fracture  of 
skull.  8  and  9  are  classed  together  as  '■  rational "  symptoms,  the  rest  be- 
ing called  "  sensual."  Abnormal  mobility  is  the  only  pathognomonic  sign. 
One  or  more  of  the  above  hst  may  be  absent,  e.g.,  an  impacted  fi-acture 
presents  neither  crepitus  nor  abnormal  mobility.  Swelling  is  due  to  ex- 
travasation of  blood  at  first,  and  afterward  often  to  oedema  and  slight  in- 
flammation. Dis^Dlacements  are  of  several  kinds,  viz. : — angular,  transverse, 
longitudinal,  and  rotatory.  In  longitudinal  displacement  the  fragments 
usually  overlap  and  thus  cause  shortening.  In  rare  cases  they  are  j)ulled 
asunder  ;  thus  lengthening,  of  coui-se,  results.  A  good  example  of  rotatory 
disj)lacement  is  that  v/hich  causes  eversion  of  the  foot  in  fracture  of  the 
neck  of  the  femur.  Besides  impaction,  displacement  of  the  fi-agments  or 
intervening  blood  may  prevent  crepitus.  The  soft  crepitation  caused  by 
effusions,  especially  those  into  tendinous  sheaths,  also  the  grating  of  cer- 
tain rheumatic  affections,  must  not  be  mistaken  for  crepitus.  Diagnosis  is 
rarely  difficult  except  when  only  one  of  two  mutually  supporting  bones  is 
broken,  or  when  there  is  impaction.  In  the  former  case  there  is  little  or 
no  deformity,  in  the  latter  no  crej^itus  or  increased  mobility.  Careful 
measurement,  inspection,  or  palpation  usually  settle  the  question.  Prog- 
nosis.— Simple  fractures,  when  properly  treated,  almost  always  recover 
without  deformity.  In  some  bones,  e.g.,  the  clavicle,  sHght  deformity  is 
to  be  expected.  Compound  fractures  are  hable  to  numerous  serious  and 
sometimes  fatal  complications.  The  chief  of  these  are  :  1,  decomposition 
in  the  wound ;  2,  extensive  gangrene  of  crushed  or  dead  jiarts  ;  3,  pro- 
gressive suppuration  ;  4,  accompanying  protracted,  exhausting  fever ;  5, 
erysipelas  ;  6,  septicsemia  ;  7,  pyaemia  ;  8,  tetanus ;  9,  delirium  tremens. 
The  prognosis  of  a  compound  fracture  may  be  to  a  great  extent  inferred 
from  what  will  be  written  about  the  question  of  amputation.  Occasionally 
a  fracture  resists  all  ordinary  means  employed  to  procure  union — "  un- 
united fracture." 

Union  in  Fracttjhe. — In  the  first  week  the  suiTounding  soft  parts  are 
found  swollen  and  the  seat  of  inflammatory  effusion.  More  or  less  blood 
is  extravasated  about  the  fractiu-e  and  in  the  medullary  cavity  at  the  same 


86  FEACTUEES. 

point.  Amount  of  escaped  blood  very  variable.  During  the  third  week 
the  corpuscles  or  leucocytes  which  ci'owd  the  effusion,  produce  either 
fibrous  tissue  or  cartilage.  Later  still,  soft  young  bone  appears  in — 1,  the 
medullar}'-  cavity ;  2,  beneath  the  periosteum ;  3,  outside  the  periosteum 
in  the  periphery  of  the  fibrous  or  cartilaginous  swelling  round  the  ends  of 
the  bones  (which  swelling  is  called  "  callus  ").  A  new  periosteum  forms 
outside  the  callus.  The  bony  callus  consists  entirely  of  spongy  substance. 
Subsequently  the  medullary  cavity  is  restored,  the  excess  of  new  bony 
uniting  material  removed,  and  that  which  remains  gradually  becomes  com- 
j:)act  and  hard.  When  firmly  and  steadily  set  and  supported,  fractures 
unite  directly,  new  bone  only  being  formed  between  and  not  around  the 
fragments.  In  other  words,  there  is  then  no  "  provisional  callus."  Very 
little  callus  in  flat  bones  ;  very  little  external,  but  a  good  deal  of  internal 
{i.e.,  inside  the  spongy  sj)aces),  in  spongy  bones.  The  new  ossification  is 
visually  in  fibrous  tissue  in  adults,  but  is  preceded  by  cartilage  in  children. 
The  cells  which  are  the  agents  of  the  process  escape  from  the  blood-vessels. 
Complete  ossific  union  requires  a  period  of  one  to  two  months.  Restora- 
tion of  the  medullary  canal  and  absorption  of  the  external  or  provisional 
callus  requires  four  or  five  months  more.  Union  in  compound  fractures 
results  from  organization  and  ossification  of  granulations  which  gTOw  fi'om 
the  ends  of  the  bones  and  from  the  neighboring  periosteum.  The  process 
is  essentially  the  same  as  that  of  union  of  simple  fi-actures.  Frequently 
the  ends  of  the  fragments  die,  and  then  the  sequestra  are  cast  off  by  the 
growth  beneath  them  of  granulations  which  absorb  the  hard  parts  of  the 
adjacent  living  bone.  Granulations  possibly  dissolve  the  lime  salts  of  bone 
by  developing  lactic  acid.  Many  compovuid  fractures  have  the  external 
wound  healed  so  rapidly,  that  they  really  unite  just  like  simj^le  fractures. 
A  bare  piece  of  bone  does  not  usually  begin  to  granulate  till  about  eighth 
to  tenth  day.  In  meantime,  it  is  of  a  yellow  color.  Dead  bone  is  white  or 
gray  or  blackish.  Compound  fi-actui'es  reqtdre  for  uniting  three  times  as 
long  as  simple  fractiu'es. 

Delayed  Union  and  Non-Union  of  Fit^cTUEEs. — Occurs  naturally  in  some 
situations,  as  in  intracapsular  fracture  of  neck  of  femui*,  ditto  of  neck  of 
humerus,  fractm-e  of  olecranon,  and  of  patella.  Causes. — Predisposing: 
1,  bad  nutrition ;  2,  debility  from  repeated  hemon-hage ;  3,  specific  dis- 
eases of  blood,  e.g.,  sciuws^,  the  continued  fevers;  4,  cancerous  cachexia; 
5,  osteomalacia.  Local  causes  are  :  1,  too  loose  a  dressing  ;  2,  too  large  a 
gap  of  bone  to  fill  up,  perhaps  owing  to  loss  of  a  large  portion ;  3,  too 
early  motion.  Too  loose  a  dressing,  aE;d  repeated  meddling  with  and 
disturbing  a  fractm-e,  are  by  far  the  commonest  causes.  In  ununited 
fracture,  as  the  condition  is  called,  there  is  usually  fibrous  union,  some- 
times anew  synovial  membrane  and  actual  false  "joint."  It  is  rare  for 
there  to  be  no  union  at  all  between  the  fragments. 

D'eatment  of  Simple  Fracture.— Thiee  main  indications :  1,  reduction 


FRACTUEES. 


87 


or  setting  ;  2,  keeping  in  proper  position  till  firm  union  has  taken  place ; 

3,  prevention  or  treatment  of  complications.  Setting  ;  extension,  counter- 
extension,  manipulation,  relaxation  of  muscles  by  flexion  of  joints  or  by 
ansesthesia,  occasional  propriety  of  dividing  tendons.  Compound  fractures 
with  protrusion  may  require  skin  wound  to  be  enlarged  or  end  of  project- 
ing fragment  to  be  sawn  off.  Apparatus  :  two  kinds,  "fixed"  and  "mov- 
able." The  "  fixed  "  are  such  as  plaster-of -Paris,  starch  bandage,  gum  and 
chalk,  moulded  mill-board,  gutta-percha,  poro-plastic,  leather,  Hyde's  felt, 
etc.  The  "movable  "are  the  ordinary  fracture-box,  Cline's  splints,  Lis- 
ton's  sj)lint,  Mclntyre's  splint,  etc.  The  difference  in  the  two  varieties 
consists  in  this — the  "  fixed  "  ajDparatus  is  moulded  specially  to  the  indi- 
vidual case  to  which  it  is  appHed,  while  the  "movable"  splints  can  be 
adapted  by  fitting  and  padding  to  various  successive  cases.  Some  of  the 
so-called  "  fixed  "  are  not  less  movable  than  the  other  class.  To  all  these 
may  be  added  the  inclined  plane,  extension  by  weights  or  elastic  bands, 
support  by  sand-bags,  etc.  Great  difference  of , opinion  as  to  relative  value 
of  the  above  apparatus.  Many  English,  and  more  Continental  surgeons 
apply  a  solid  firm  dressing,  such  as  the  starched  bandage  and  mill-board, 
as  soon  as  possible  after  the  occurrence  of  a  simple  fracture,  and  after 
most  compound  fractures  too.  Other  English  surgeons  teach  that  this  is 
dangerous.  In  applying  such  a  firm  dressing,  attend  strictly  to  the  follow- 
ing rules  :  1,  place  no  bandage  next  the  skin  ;  2,  line  thickly  with  cotton 
wool  or  wadding  ;  3,  include  the  joints  both  above  and  below  the  fracture  ; 

4,  leave  the  toes  or  fingers  bare,  and  never  fail  to  examine  them  carefully 
twenty-four  hours  after  applying  apparatus.  Indications  for  cutting  up 
apparatus  wholly  or  partially  are  :  severe  pain  anywhere  beneath  it ;  signs 
of  obstructed  circulation  in  toes  or  fingers,  or  looseness  of  the  apparatus. 
Starched  bandages  tend  to  loosen  and  require  trimming.  In  adjusting 
any  fracture-apparatus,  carefully  avoid  disturbing  fracture.  Starched  band- 
age requires  twenty-four  hoiirs  to  dry,  plaster-of-Paris  takes-  a  quarter  of 
an  hour  to  set ;  borax  will  retard,  and  common  salt  hasten,  setting  of  lat- 
ter. Leather,  poro-plastic,  and  mill-board  are  softened  in  hot  water  before 
moulding.  Starch  should  be  aj^plied  with  palm  of  hand  after  bandage  has 
been  put  on  dry.  Leather  and  gutta-jjercha  are  better  adajDted  to  angu- 
lar parts,  e.c).,  shoulder,  than  is  mill-board  ;  but  gutta-percha  is  rather 
dear,  and  leather  very  dear,  Salter's  swing.  Cradle  to  keep  off  bed- 
clothes. With  the  use  of  a  fracture-box  or  Cline's  splints,  correct  j)Osition 
is  obtained  by  pads  of  lint  or  cotton-wool.  For  time  of  each  appHcation, 
vide  Special  Fractures.  Itching  of  skin  is  relieved  by  cleanHness,  olive 
oil,  etc.  Severe  pain  may  require  morphia  subcutaneously  ;  but  it  is  usu- 
ally a  sign  that  apparatus  requires  readjusting.  Pain  shoiild  never  be 
neglected. 

Compound  Fractures. — Special  Notes  on  TJieir  Treatment. — Question  of 
amputation.     Consider,  1,  cause  of  fracture  (was  there  much  crushing  or 


OO  FRACTURES. 

twisting  force  ?) ;  2,  main  arteries  or  veins  torn  ?  3,  amount  of  hemorrliao-e  ; 
4,  condition  as  to  collapse,  reaction,  etc.  Depth  and  extent  of  bone-injuiy 
should  also  be  considered.  Injmy  to  nerves,  even  large  ones,  not  of  much 
account.  Kupture  of  large  artery  not  an  absolute  indication  for  amputa- 
tion. Will  the  Hmb  be  useful,  even  if  patient  does  recover,  or  will  it  be  in 
tlie  way  ? 

Always  treat  the  wound  in  a  compound  fracture  very  gently.  After  first 
dressing  and  cleaning,  never  probe  or  touch  it  if  possible  till  the  wound  is 
quite  fistulous.  Then,  if  necrosis  is  found,  treat  it  like  necrosis  from  os- 
teitis. A  firm  starched  or  plastered  bandage,  apphed  as  soon  as  possible 
after  accident,  is  the  treatment.  It  should  be  thickly  lined  with  cotton 
wadding.  Dress  the  wounds  either  by  Lister's  strict  plan  or  with  oakum. 
Extensive  discharge  or  large  wounds  may  require  a  fracture-box,  inter- 
rupted or  not.  Generally,  windows  in  a  plaster  bandage  suffice.  Attend 
to  complications  as  they  arise.     "Immersion  treatment." 

Treatment  of  Ununited  Fracture. — 1,  Rubbing  fragments  together  ;  2, 
blisters  or  iodine  externally  ;  3,  firing  neighboring  skin  ;  4,  acupuncture 
needles  left  for  a  few  days  in  the  false  joint ;  5,  electro-puncture  ;  6,  seton  ; 
7,  scraping  ends  of  fragments  with  a  tenotomy-knife  ;  8,  excision  of  ends 
of  fragments  ;  9,  scraping  back  periosteum  and  then  excising ;  10,  sutures  ; 
11,  driving  in  ivory  pegs  ;  12,  metal  screws.  But  in  many  cases,  the  pro- 
longed application  and  skilful  management  of  a  plaster  bandage  are  suffi- 
cient.    Attend  to  general  health.     Give  phosphates. 

Fractures  United  with  Deformities. — Treatment. — If  there  is  malposition 
in  a  compound  fracture,  and  the  wound  is  heahng  rapidly,  do  not  try  to 
rectify  till  the  wound  is  healed.  Remedies  for  obHquity  are  bandaging, 
extension  by  weights,  manij^vdation,  re-breaking  (by  flexion  or  extension), 
cutting  oj)erations.  Two  cutting  operations  :  1,  subcutaneous  osteotomy. 
Small  incision  down  to  bone.  Gimlet-hole  through  bone.  Insert  key-hole 
saw,  and  saw  partially  through,  first  one  side,  then  the  other.  Lastly, 
break  the  bone  in  two.  2.  Antiseptic  osteotomy.  Of  course  bloody  oper- 
ations are  dangerous,  but  the  danger  is  very  small  with  antiseptic  treat- 
ment. 

Special  Fractures. — Acetabulum,  Fracture  of. — Causes. — Great  violence 
applied  to  femur.  Varieties. — Two.  Firstly,  fracture  of  rim  of  acetabulum  ; 
crepitus,  dislocation  of  femur,  probably  easy  to  reduce,  but  very  difficult 
to  keep  in  position.  Secondly,  fracture  through  bottom  of  acetabulum. 
Head  of  femiu'  may  be  driven  through  acetabulum  into  pelvis,  and  even 
impacted.  And  there  are,  very  hkely,  severe  injuries  to  neighboring  parts. 
Treatment. — Extension;  rest;  long  splint,  weight,  or  fixed  apparatus. 
Frognosis. — Shortening  of  limb  maj'  be  expected. 

Acromion,  Fracture  of. — Signs. — Flattening  of  shotdder  ;  inability, 
entii'e  or  partial,  to  raise  arm  ;  crepitus  ;  arm  feels  to  patient  as  if  drop- 
ping off ;  the  fragments  can  be  felt  separated.     Frognosis. — Union  is  not 


FRACTUEES.  89 

unlikely  to  be  ligamentous.  Treatment. — Support  elbow  well,  so  as  to 
make  use  of  head  of  humerus  for  a  splint.  Fix  the  arm  as  firmly  as  can  be 
done  without  binding  it  too  closely  to  the  side. 

Clavicle,  Fracture  of. — Causes. — Almost  always  indirect  violence,  e.g., 
falls  on  shoulder.  Situation. — 1  (most  common),  great  concavity  ;  2,  acro- 
mial end,  between  or  external  to  coracoclavicular  ligaments  ;  3,  sternal  end 
(inside  rhomboid  ligament  very  rare).  Chai^acter. — Oblique,  when  from 
iudu-ect  violence  in  adults  ;  transverse  in  children  ;  transverse  or  comminu- 
ted from  direct  violence.  Displacement.  — 1,  Fracture  in  middle  of  bone — 
outer  fragment  downward  and  inward  beneath  inner  fragment,  the  acro- 
mial end  being  rotated  forward  ;  2,  fracture  of  acromial  end  outside  coraco- 
acromial  ligaments  — outer  fragment  strongly  forward,  inward,  and  slightly 
downward.  Fracture  between  conoid  and  trapezoid  ;  deformity  almost 
nil,  or  else  as  in  last  variety  (Gordon)  ;  3,  fracture  of  sternal  end  inside 
rhomboid  ligament — outer  fragment  horizontally  forward,  simulating  dis- 
location. 

Additional  Symptoms. — Flattening  of  shoulder,  prominence  of  inner 
fragment,  crepitus,  inability  to  raise  arm,  tenderness.  ComjjUcations. — 
Occasional  injury  to  subclavian  vein  or  brachial  plexus.  Treatment. — Three 
indications  ;  1,  keep  shoulder  and  scapular  fragment  outward ;  2,  correct 
rotation  forward  of  shoulder  ;  3,  elevate  shoulders.  Best  results  from  re- 
cumbent, supine  position,  for  two  or  thi-ee  weeks.  Bandages,  pads.  Many 
special  apparatus. 

Coccyx,  Fracture  of. — Causes. — Parturition,  falls,  and  blows.  Treatment. 
— Regulate  bowels.     Eest. 

Colles's  Fracture. — See  Fbacture  of  Eadius. 

Coracoid  Process,  Fracture  of. — Causes. — Blows  ;  dislocation  of  hume- 
rus. Prognosis. — Ligamentous  union,  to  be  expected,  it  is  said.  Treat- 
ment.— Eest.  Biceps  and  coracobrachialis  to  be  relaxed  by  flexing  elbow 
and  bringing  arm  across  front  of  chest.  Uncomplicated  fracture  of  cora- 
coid process  is  extremely  rare. 

Facial  Bones,  Fracture  of.  —  Cause.  —  Direct  violence.  Prognosis.  — 
Almost  equally  good  in  both  compound  and  simple  fractures.  Great  de- 
formity is  sometimes  unavoidable.  Treatment. — See  Fracture  of  Nasal 
Bones,  etc. 

Femur,  Fracture  of. — Three  main  divisions  :  1,  of  upper  extremity ;  2, 
of  shaft ;  3,  of  lower  extremity.  1.  Fi'acture  of  ujaper  extremity,  three 
subdivisions,  viz. :  a,  intraca^Dsular  fracture  of  neck  of  femur  ;  h,  extracap- 
sular fracture  of  neck  of  femur  ;  c,  fracture  of  the  trochanters  not  involving 
the  neck. 

Fracture,  Intracapsular,  of  Neck  of  Femur. — Fracture  altogether  within 
capsule  of  hip-joint.  Causes. — Predisposing — old  age,  consequent  senile 
atrophy  and  lessened  obliquity  of  neck  of  femur.  Exciting  cause,  veiy 
trifling,  e.g.,  slight  fall,  or  even  tui-ning  in  bed.     Almost  all  intracapsular 


90  FEACTURES. 

fractures  occur  in  old  age.  More  common  in  female  sex.  Signs. — 1,  loss 
of  power :  limb  cannot  be  raised  from  tlie  bed  (except  in  rare  cases)  ;  2, 
flattening  in  region,  of  trochanter  ;  3,  trochanter  rises  above  Nelaton's  line  ; 

4,  it  moves,  on  rotation,  in  an  arc  of  a  circle  smaller  than  on  the  sound  side  ; . 

5,  crepitus  ;  6,  tenderness  ;  7,  eversion  (excej)t  in  rare  cases) ;  8,  shortening, 
|-  to  1  inch  at  first,  later  on,  owing  to  capsule  giving  way,  sometimes  2^ 
inches.  Pathology. — Lower  fragment  usually  outside  upper.  Very  little 
extravasation.  Union. — By  fibrous  tissue.  Sometimes  nil,  rarely  osseous. 
Diagnosis. — See  Extracapsular  Fracture.  Prognosis. — The  unavoidable 
confinement  to  bed  in  some  cases  depresses  the  system  fatally.  In  any  case 
lameness  and  shortening  are  to  be  expected.  Treatment. — Bed  for  two  or 
tlir^e  weeks.  Pillows  beneath  knee.  Then  leather  or  poro-plastic  sj)lint 
to  hip  ;  crutches  and  gentle  attempts  to  use.  In  strong  constitutions,  at- 
tempt to  obtain  firmer  union  by  longer  rest  and  use  of  starch  bandage. 
Good  diet.     Water-bed.  * 

Fracture,  Extracajysular,  of  Neck  of  Femur. — Two  kinds:  1,  simple',  2, 
impacted.  Fracture  wholly,  or  partially  outside  capsule  of  joint.  Cause. — 
Direct  and  considerable  violence.  Signs. — Firstly,  when  not  impacted  :  1, 
inabihty  to  raise  Hmb  ;  2,  bruising  and  swelling  of  hip,  indicating  great  ex- 
travasation ;  3,  crepitus  at  great  trochanter,  which  may  sometimes  be  dis- 
tinctly felt  to  be  in  several  pieces ;  4,  great  pain  and  tenderness  ;  5,  usually 
very  marked  eversion,  sometimes  inversion  ;  6,  shortening,  1^  to  2^  or  even 
S^  inches.  Secondly,  impacted  fracture.  Symptoms  less  marked  than  if 
there  is  no  impaction.  Less  eversion  ;  little  or  no  crepitus,  only  slight 
shortening,  not  more  than  an  inch.  But  there  is  local  tenderness,  fol- 
lowed in  a  day  or  two  by  thickening  over  great  trochanter.  Treatment. — 
Extracapsular  fracture  is  to  be  treated  on  similar  principles  to  those  ap- 
plied in  treatment  of  fractured  shaft  of  femiu'.  Seek  for  union  by  securing 
immobility  with  Liston's  splint,  etc.  Compress  trochanter  with  a  belt  round 
lii23S. 

Fracture  of  Trochanter  Major.— Signs. — Local  pain,  tenderness,  crepi- 
tus, eversion,  no  shortening.  Fracture  of  this  without  fracture  of  neck  or 
shaft  of  femur  almost  unknown. 

Fracture  of  Shaft  of  Femur. — Classified  according  to  position,  whether 
in  upper,  middle,  or  lower  third.  Signs. — Typical  signs  of  fracture. 
Displacement. — In  upper  and  middle  thirds  the  upper  fi'agment  inclines 
forward  and  usually  outward,  lower  fragment  inclines  inward  and  is  ro- 
tated outward.  Causes  of  the  displacement  are :  1,  muscular  action  of 
psoas,  iliacus,  adductors,  etc.;  2,  lower  fragment  forces  upper  fragment 
outward  at  time  of  accident.  Treatment. — 1,  position  merely  ;  2,  Liston's 
splint ;  3,  double  inclined  plane  ;  4,  extension  by  a  weight ;  5,  anterior 
splint ;  6,  starched  bandage  or  other  fixed  apparatus.  1.  Position. — Lay 
limb  on  outer  side,  with  knee  bent.  In  infants,  merely  lay  limb  straight 
out  in  bed,  taking  weight  of  clothes  off  with  a  cradle  (preserve  body- 


FRACTUKES.  91 

warmth  in  latter  case).  2.  Listen's  splint. — Length,  it  should  reach  from 
a  hand's  length  below  heel  to  a  hand's  breadth  below  axiUa.  Pad  ankle 
well.  Turn  bandage  twice  round  ankle  and  instep,  thgn  fix  foot  to  siDlint. 
Avoid  crushing  the  small  toes.  Bandage  to  just  above  the  knee  with 
figures-of-eight.  "Kettle-holder"  on  inner  aspect  of  thigh.  Perinceal 
band.  Extension  and  setting.  Apparatus  for  combining  Liston's  sj)lint 
with  continuous  extension  by  elastic  bands  or  by  weight  and  pulleys. 
Sand-bags.     Bottom  of  bed  should  be  level.     3.  Double-inclined  plane. 

4.  Extension  by  weight. — Stirrup  of  wood  and  plaster.  Strapping  ex- 
tending up  to  the  knee.  Bandage  over  strapping.  Raise  foot  of  bed  on 
blocks.     Weight  consists  usually  of  sand-bags  or  tins  of  shot,  '5  to  10  lbs, 

5.  Anterior  ii'on  splint. — May  be  combined  with  a  plaster  splint.  6. 
"  Fixed "  apparatus  :  plaster-of-Paris,  starch  bandage,  etc.  Unless  at- 
tended to  with  great  vigilance,  liable  to  have  very  bad  results  in  fractured 
thigh.  The  hip  should  be  thoroughly  fixed — not  an  easy  matter.  Frac- 
ture of  femur,  lower  third,  that  is,  near  knee-joint. — Upper  end  of  lower 
fragment  projects  backward.  Hence  these  cases  should  be  treated  with  the 
knee  semi-flexed. 

Compound  Fracture  of  Femur. — Very  dangerous.  But  amputation  for 
it  is  extremely  fatal.     Treat  each  case  according  to  its  own  peculiarities. 

Fibula,  Fracture  of. — Tibia  acts  as  a  splint,  making  diagnosis  difficult. 
Seek  for  crepitus  and  increased  mobility  by  pressing  fibula  at  different 
points  against  the  tibia.  Occurrence  frequent.  Treatment. — Cline's  (side) 
sx)lints,  or  some  immovable  apparatus.  Fracture  of  fibula  about  two  or 
three  inches  above  ankle,  with  ruj)ture  of  internal  lateral  ligament  and  dis- 
location of  foot  outward  is  called  "  Pott's  Frapture. "  ySfee  Dislocation  of 
Ankle. 

Fracture  of  Forearm  may  be  of  radius  or  ulna  separately,  or  of  both 
bones.     See  Fractuke  of  Radius,  Ulna,  etc. 

Humerus,  Fracture  of. — Nine  kinds,  viz.:  4  of  the  upper  end,  1  of  the 
shaft,  and  4  of  the  lower  end. 

Intracapsular  of  Neck  of  Humerus  (anatomical  neck,  of  course). — Cause. 
— -Direct  violence.  Signs. — Those  of  a  severe  injury  to  the  shoulder-joint, 
causing  paralysis,  swelling,  etc.,  but  very  little  shortening  (J  inch)  or  de- 
formity. Indeed,  this  fracture  is  diagnosed  by  the  absence  of  the  marked 
symptoms  of  other  fractures  and  of  dislocation.  Often  impacted.  When 
not  impacted,  there  is  crepitus.  Prognosis. — Expect  bony  union,  with,  very 
likely,  excess  of  new  bone.  Treatment. — Pad  in  axilla,  leather  shoulder-cap, 
bandage,  and  sling.  Whole  arm  should  be  bandaged  gently  and  evenly. 
Sling  should  support  hand  rather  than  elbow  in  all  fractures  of  humerus. 
Impacted  fractures  not  to  be  disturbed. 

Extracapsidar  Fracture  of  Neck  of  Humerus,  i.e.,  through  surgical  neck. 
Signs. — Sharp  end  of  lower  fragment  projects  into  axilla  or  beneath  cora- 
coid.     But  head  of  humerus  remains  in  glenoid  cavity.     Distinct  crepitus. 


92 


FRACTURES. 


Shortening,  1  inch.  Pain  from  irritation  of  brachial  plexus.  Prognosis. — 
In  rare  cases  the  bone  atrox^hies.  Treatment. — Bandage  limb  from  finger 
upward.  Pad  in  axilla.  Carry  elbow  forward  and  inward.  Apply  a 
leather  cap  to  shoulder  and  outer  side  of  upper  arm.  Support  hand,  but 
not  elbow,  with  a  sling.     Erichsen's  bent  leather  splint. 

Separation  of  Upper  Epiphysis  of  Humerus  resembles  accident  last  de- 
scribed, but  the  upper  end  of  the  shaft  forms  a  remarkable  and  smooth 
projection  beneath  the  coracoid  process.  The  patient  is  usually  very 
young,  and  must  be  less  than  twenty.    Treat  like  fracture  of  siu'gical  neck. 

Fracture  of  Great  Tuberosity. — Cause. — Direct  violence.  Signs. — In- 
creased breadth  of  shoulder.  The  tuberosity  is  dragged  backward  by  the 
muscles  inserted  into  it,  and  the  head  of  the  humerus  forward  beneath  the 
coracoid  (a  semi-dislocation)  by  the  pectoralis  major,  etc.  Crepitus.  Tir.at~ 
ment. — Pad  in  axilla  and  leather  cap  on  shoulders,  or  rest  in  bed  with  the 
arm  extended. 

Fracture  of  Shaft  of  Humerus. — Causes.  ^Direct  violence,  falls  upon  the 
elbow,  and,  not  rarely  as  compared  with  other  bones,  muscular  action. 
Signs. — Typical.  Treatment. — Two  or  three  splints,  one  being  an  angular 
elbow-splint.  Support  hand,  but  not  elbow,  in  a  sling.  Stromeyer's  cush- 
ion for  compound  fracture  of  humerus  {vide  Bryant's  "Surgery,"  p.  942). 
Danger  of  delayed  union  in  fracttu'e  of  shaft  of  humerus. 

Fracture  of  Lower  End  of  Humerus. — Four  kinds:  1,  transverse  frac- 
ture ;  2,  fracture  of  either  condyle  ;  3,  fracture  between  the  condyles  into 
the  joint  (this  is  always  combined  with  transverse  fracture) ;  4,  separation 
of  the  epiphysis.  Causes. — Usually,  falls  on  the  bent  elbow.  Sigyis. — 1,  Of 
transverse  fracture.  It  may  be  either  above  or  below  the  condyles.  The 
symptoms  are  given  in  the  following  diagnosis  between  it  and  the  injury 
with  which  it  is  most  frequently  confounded,  viz.,  dislocation  of  radius 
and  ulna  backward : 


The  Fkactuke. 

1.  Crepitus. 

2.  Easily  reduced,  but  deformity  at  once 

reappears. 

3.  Prominence     of   lower  end   of    upper 

fragment  of  humerus  projects  for- 
ward above  the  bend  of  the  skin  in 
front  of  the  elbow- joint. 

4.  Internal  condyle  in  normal  relation  to 

olecranon. 


The  DisiiOCATioN. 

1.  No  crepitus. 

3.  Not  so  easily  reduced.     But  then  does 
not  reappear. 

3.  Prominence  of  lower  articular  surface 

of  humerus  projects  forward  beneath 
the  bend  of  the  skin  in  front  of  the 
elbow- joint. 

4.  Distance    increased   between    internal 

condyle  and  olecranon. 


2.  Signs  of  fracture  of  condyles.  Pain.  Crepitus  produced  by  direct 
manipulation,  and  by  pronation  and  supination  of  foreai*m. 

3.  Signs  of  fracture  between  condyles  into  joints.  Pain.  Crepitus. 
Effusion  into  joint  perhaps  considerable.  The  pathognomonic  sign  is  the 
increased  breadth  from  condyle  to  condyle. 

4.  Signs  of  separation  of  epiphysis.     Like  those  of  transverse  fractui*e  ; 


FRACTTJEES.  93 

but  the  crepitus  is  softer,  and  the  patient  is  necessarily  young.  In  every 
obscure  case  of  injury  to  the  elbow,  make  the  patient  place  his  hands  one 
above  the  other  upon  his  head,  then  bring  his  elbows  together  and  com- 
pare them,  using  your  eyes  and  fingers.  Treatment  of  fractm-es  of  lower 
end  of  humerus.  Reduce  and  put  up  in  lateral  angular  splints,  with 
elbow  at  right  angles  and  hand  in  sling.  When  elbow  tends  to  displace- 
ment backward,  apply  angular  sphnt  behind,  and  a  short  splint  in  front 
of  humerus.  Passive  motion  in  three  weeks — in  one  week  if  the  fractiu-e 
extends  into  the  joint.  Complication  of  fracture  of  humerus,  injury  of 
musculo-sjDiral  nerve.     See  Injuries  of  Nekves. 

Hyoid  Bone,  Fracture  of. — Causes. — Direct  violence:  rarely  muscular 
action.  Signs. — Crej)itus,  etc.,  with  difficulty  in  swallowing,  speaking, 
and  sometimes  even  in  breathing.  Eeduce  with  one  finger  in  patient's 
mouth. 

Jaw,  Lower,  Fracture  of. — Cause. — Great  and  direct  violence.  Situation. 
— Order  of  frequency,  near  canine  tooth,  at  angle,  at  symphysis.  Neck  of 
condyle  and  coronoid  process  are  very  unusual  places.  Occasionally  mul- 
tiple. Signs. — Pain,  tenderness,  mouth  can  scarcely  be  opened,  saliva 
dribbles,  crepitus,  deformity  ;  frequently  bleeding,  for  the  fracture  often 
opens  through  the  mucous  membrane  of  the  mouth.  Prognosis. — Union 
often  slow.  Treatment. — The  interdental  sphnt  cannot  be  too  strongly 
recommended.  It  should  almost  always  be  used.  See  that  no  tooth  or 
foreign  body  lies  between  the  fragments,  if  the  fracture  is  an  open  one 
{see  Lyon's  "St.  Bartholomew's  Hospital  Rejiorts,"  1879).  Wire  round 
teeth  damages  them.  Thomas  drills  the  fragments  and  inserts  a  silver 
suture. 

Leg,  I^racture  of. — See  Fkactuee  of  Tibia  akd  Fibitla. 

Metacarpus  and  Metatarsus,  Fractures  of. — Causes. — Direct  violence. 
Treatment. — On  general  principles. 

Nasal  Bones,  Fracture  of. — Occasional  emphysema  from  coincident  in- 
juiy  to  frontal  sinuses.  Difficulty  in  reduction  and  in  preventing  defor- 
mity. A  smooth  silver  female  catheter  may  be  inserted  into  the  nostrils  and 
used  to  raise  the  dejDressed  bone.  Adams'  and  Gamgee's  apparatus  for  pre- 
ser-^-ing  the  position  of  the  bones.  Vulcanized  india-rubber  dilator  intro- 
diiced  empty  and  then  fiUed  with  water  has  great  power  to  raise  a  flattened 
nose.  Above  remarks  apply  both  to  fracture  of  nasal  bones  and  of 
septtmi. 

Patella,  Fracture  of. — Two  kinds,  one  ti'ansverse  and  usually  the  result 
of  muscular  action,  or  mus<iular  action  combined  with  violence  ;  the  other 
stellate,  Y-shaped,  or,  perhaps,  quite  simple,  but  not  transverse,  and  always 
caused  by  direct  violence.  The  former  fracture  often  occurs  in  missing  a 
step  whilst  walking  down-stairs,  or  in  some  similar  and  trivial  manner.  In 
it  the  fragments  generally  separate  widely,  while  in  the  stellate  fi-acture 
there  may  be  little  or  no  separation.     Consequently  the  former  always 


94  FKACTUEES. 

ends  in  fibrous  union,  the  latter  frequently  in  bony  union.  Sulcus  be- 
tween fragments  in  the  transverse  fracture.  Great  swelling  and  effusion 
into  knee-joint.  Inability  to  extend  knee.  Treatment. — Rest  in  horizontal 
position  or  with  heel  raised.  Straight  splint  along  back  of  Hmb.  Elastic 
straps  to  pull  upper  fragment  downward  and  lower  upward.  Figure-of-eight 
bandage.  Callander's  arrangement  of  weight,  strapping,  and  pulleys. 
Malgaigne's  hooks.  Malgaigne's  hooks  fixed  into  plaster  after  Spence's 
plan.  No  doubt  one  of  the  chief  indications  is  to  reduce  the  effusion  into 
the  knee-joint  without  delay.  It  has  been  recommended  to  do  this  with 
the  aspirator ;  but  it  can  be  effected  to  a  great  extent  by  bandaging  and 
compressing,  using  plenty  of  cotton-wool.  Hence  a  starch  and  mill-board 
apparatus  is  useful. 

Compound  Fracture  of  Patella. — Very  serious  indeed,  but  not  always 
requiring  amputation. 

Pelvis,  Fractures  of. — May  occur  in  part  or  parts  of  the  os  innominatum, 
but,  for  practical  purposes,  are  best  classified  into  those  which  injure  a 
large  part  of  the  bone,  e.g.,  the  body  or  rami  of  the  pubes,  and  those  which 
merely  chip  off  a  prominence  like  the  ant.  sup.  spine  of  the  ilium.  The 
former  are  very  serious,  from  the  violence  often  done  to  the  pelvic  viscera, 
especially  the  bladder.  Cause. — Usually  a  vehicle  passing  over  the  part. 
Signs. — Crepitus,  pain  (inability  to  stand,  in  the  first  or  serious  class  of 
cases).  Often  signs  of  ru^Dtured  bladder,  lu'ethra,  or  rectum.  Treatment. — 
Pass  a  catheter  to  examine  the  state  of  the  bladder.  Rest  in  bed.  Band- 
age round  hips  and  knees.  Sometimes  displaced  parts  may  be  set  by  man- 
ipulating with  the  finger  in  the  vagina  or  rectum.  See  also  Fkactuee  of 
Acetabulum,  Rupture  of  BljVdder,  etc. 

Badiics,  Fractures  of. — 1,  Of  head  ;  2,  of  neck  ;  3,  of  shaft ;  4,  of  lower 
extremity.  The  fii'st  three  are  caused  usually  by  direct  violence,  and  pre- 
sent usual  signs  of  fracture,  ^dz.,  crepitus,  pain,  etc.  Unless  the  ulna  is 
broken  also,  there  is  little  deformity.  Treatment. — For  first  three  cases  : 
An  angular  splint  to  fix  elbow  and  extend  along  back  of  forearm.  Fore- 
arm midway  between  pronation  and  sujoination.  Short  sphnt  along  pal- 
mar surface  of  forearm.  Splints  should  be  flat  and  wide,  so  as  to  i)revent 
bandage  from  squeezing  radius  and  ulna  together.  Fingers  to  be  left  free. 
The  fourth  case,  viz.,  fracture  of  lower  end  of  radius,  is  called 

Colles's  Fracture. — Causes. — Falls  on  outstretched  hand.  Very  rarely 
direct  violence.  Especially  fi-equent  in  old  women.  Signs. — Peculiar 
spoon-shaped  deformit3^  Prominence  of  styloid  process  of  ulna.  Crepitus 
generally  absent,  or  at  least  indistinct.  Dorsal  prominence  is  nearer  the 
hand  than  palmar  prominence.  Pain  severe.  Power  of  supination  or 
pronation  lost.  Anatomy. — Upper  fragment  occasionally  imj)acted  into 
lower ;  lower  sometimes  comminuted.  Dorsal  prominence  formed  by  lower 
fragment,  palmar  prominence  by  flexor  tendons  stretched  over  lower  end 
of  upper  fragment.     Position  of  fracture  generally  about  one  inch  above 


FRACTURES.  95 

carpal  articular  surface  of  radius.  Prognosis. — If  the  deformity  can  be  re- 
moved and  the  fracture  perfectly  set  at  first,  all  should  be  well.  Other- 
■wise,  deformity  will  be  permanent,  and  stiffaess  of  the  wrist  and  fingers 
may  continue  for  many  months.  Diagnosis. — From  dislocation  of  the  wrist- 
joint,  by  the  fracture's  not  altering  the  distance  between  the  styloid  pro- 
cesses and  the  knuckles.  Treatment. — Every  effort  to  be  made  to  reduce 
and  set  properly  at  commencement.  Extension  and  counter-extension. 
Bruce  Clarke  dissected  a  specimen  in  which  reduction  was  easy,  if  the  ex- 
tensors of  the  thumb  and  carpus  (radial  side)  were  first  relaxed  by  ap- 
propriate movements  of  the  hand  and  thumb.  Apparatus  used  are  of  three 
kinds  :  First,  Nelaton's  pistol-shaped  splint,  applied  along  palmar  side 
separately,  or  along  dorsal  side  in  conjunction  with  a  short  spHnt  on  pal- 
mar side  of  shaft  of  radius.  Thick  dorsal  pad  opposite  lower  fi-agment. 
Palmar  pad  thickest  on  radial  border  (the  word  palmar  applies  here  to 
the  arm  only,  not  the  hand).  Passive  exercise  of  fingers  after  second  week. 
Second,  long  straight  posterior  and  siiox't  anterior  sphut,  padded,  like 
Nelaton's  apparatus.  In  this  case  the  hand  is  often  left .  entirely  free,  so 
that  the  fingers  may  be  exercised,  and  the  weight  of  the  hand  may  keep 
the  radial  side  of  the  wrist  extended.  Third,  Gordon's  splints.  Hand 
kept  m  prone  position.  Two  straps.  No  bandages.  Eidge  on  radial 
side  of  palmar  splint.  "  Overhanging  lip  "  on  radial  side  of  lower  end  of 
dorsal  splint.  Gordon  says  that  impaction  is  uncommon  in  this  fracture. 
Lower  fragment  of  i-adius  occasionally,  bixt  rarely,  displaced  forward  in- 
stead of  backward.  Dr.  L.  S.  Pilcher  demonstrates  that  in  CoUes's  fi-acture 
the  strong  periosteum  on  the  back  of  the  radius  remains  untorn,  and  is 
the  main  obstacle  to  the  reduction  of  the  fracture.  To  relax  it,  bend  back 
the  hand  and  wrist.  Then  make  slight  extension  in  the  line  of  the  fore- 
arm, accompanied  by  moderate  pressure  on  the  dorsum  of  the  lower  frag- 
ment. Reduction  is  thus  effected.  The  only  apparatus  Pilcher  uses  are 
a  broad  band  of  adhesive  plaster  round  the  seat  of  fracture,  and  a  sling 
to  support  the  arm.     I  can  recommend  this  plan  from  my  own  experience. 

Itaclius  and  Ulna,  Fracture  of  Shaft  of. — Treat  like  fracture  of  either 
bone  singly.  Green-stick  fracture  not  uncommon.  Si^lints  to  be  wide, 
and  to  be  applied  whilst  hand  is  supinated. 

Ribs,  Fracture  of. — Causes. — Predisposing  :  old  age.  Immediate  are  of 
three  kinds :  1,  direct  \dolence  ;  2,  indirect  violence,  the  chest  being  com- 
pressed at  one  part  the  rib  gives  way  at  another,  just  as  a  spring  or  a  stick 
might ;  3,  muscular  action,  as  from  violent  coughing  or  severe  labor.  Sit- 
uation.— Usually  the  convexity  of  the  rib  a  few  inches  in  front  of  angle. 
Middle  ribs  most  frequently  broken,  first  and  second  ribs  rarely,  because 
protected  by  clavicle.  Signs. — Catching  pain  on  inspiration  or  coughing. 
Tenderness.  Crepitus.  Crepitus  sometimes  difficult  to  get,  esijecially 
Avhen  the  fracture  is  beneath  the  thick  muscles  of  the  back.  Press  alter- 
nately with  the  fingers  of  each  hand,  one  on  one  side,  the  other  on  the  other 


96  FEACTUEES. 

side  of  the  supposed  fracture.  Take  care  to  apply  botli  hands  to  the  same  rib 
Breathing  shallow  and  abdominal.  Other  symptoms  often  arise  from  com- 
plications, e.g.,  hsemoptysis.  Complications. — 1,  Emphysema  ;  2,  j)neumo- 
thorax  ;  3,  hsemothorax  ;  4,  haemoptysis  ;  5,  wounds  of  heai*t,  pericardium,  or 
gi-eat  vessels ;  6,  wounds  of  intercostal  vessels  ;  7,  etc.,  wounds  of  diaphragm 
and  abdominal  viscera,  liver,  or  spleen.  1  and  2  imply  a  wound  of  the 
lung  ;  4  implies  either  a  wound  or  bruise  of  the  lung.  Emphysema  is  far 
the  commonest  complication.  Practically,  cases  of  fractured  rib  are  classi- 
fied into  those  without  and  those  with  injury  to  the  lungs.  Secondary 
complications  are  inflammations  and  empyema.  Diagnosis. — When  crepitus 
cannot  be  obtained,  consider  generally  all  the  symptoms  present.  Prog- 
nosis.— If  there  is  no  visceral  injury,  speedy  union  with  formation  of  pro- 
visional callus  may  be  expected.  If  there  is  visceral,  injury,  then, prognosis 
dejDends  on  its  natui'e  and  amount.  The  danger  in  such  cases  is  threefold  : 
firstly,  shock  ;  secondly,  hemorrhage  ;  thirdly,  inflammation.  Treatment. 
— Broad  bandage  round  chest,  prevented  from  slipping  down  by  braces  of 
bandage  across  shoulders.  Strapping  all  round  chest,  or  extending  merely 
from  si^ine  to  sternum  over  injured  side.  In  some  cases,  bandaging  ajDpears 
to  press  the  sharp  ends  of  the  fi-agments  inward  ;  it  is  then,  of  course, 
contraindicated.  In  bad  cases,  rest  in  bed  for  a  few  days  and  moderate 
diet.  For  treatment  of  complications,  see  articles  Hemorkhage,  Injuries  of- 
Thorax,  Lungs,  etc.     Treatment  lasts  a  month. 

Sacrum,  Fracture  of, — Causes. — Either  severe  crushing  force  applied  to 
the  whole  pelvis,  or  else  gunshot  wounds.  Prognosis. — Very  bad.  Treat 
each  case  with  its  complications  on  general  principles. 

Scajnda,  Fracture  of. —  Varieties. — Four,  viz.,  1,  of  body  ;  2,  of  neck  ;  3, 
of  coracoid  process ;  4,  of  acromion  {see  Fracture  of  AcROivnoN  and  of 
Coracoid). 

Fracture  of  Body  of  Scajmla. — Causes. — Severe  direct  violence.  Signs 
(often  obscure). — Pain,  loss  of  power,  crepitus,  irregularity  in  spine  of 
scapula  if  fractm-e  passes  through  that  process.  Treatment. ~Bim(\Q.ge  pad 
over  scapula,  elbows  supported  by  a  sling.  Prognosis. — Deformity  not 
unlikely. 

Fractures  of  Neck  of  Scapula. — Two  kinds,  viz.,  1,  of  anatomical  neck, 
i.e.,  external  to  coracoid  ;  2,  of  surgical  neck,  i.e.,  internal  to  coracoid  2)ro- 
cess.  In  fracture  of  the  anatomical  neck,  the  symptoms  resemble  those  of 
dislocation  of  the  head  of  the  humerus  into  the  axiUa  ;  but  the  deformity 
produced  by  the  fi-actui-e,  though  easily  reduced,  at  once  recurs,  and  there 
is  also  crepitus.  Still,  even  these  points  wiU  not  distinguish  fracture  of 
the  anatomical  neck  of  the  scapula  from  dislocation  of  the  humerus  with 
fracture  of  the  glenoid  fossa.  Fracture  of  the  sui'gical  neck  can  be  recog- 
nized by  bearing  in  mind  that  the  coracoid  process  goes  with  the  separated 
neck,  and  is  detached  from  the  body  of  the  scapula.  All  fractures  of  the 
necks  of  the  scapula  are  excessively  rare.     Treatment. — Raise   the  elbow 


FRACTURES.  97 

•with  a  sling,  and  keep  the  parts  at  rest  with  a  pad  in  the  axilla  and  a 
bandage  round  arm  and  chest. 

Sternum,  Fracture  of. — Causes. — Great  direct  violence  ;  rarely  indirect ; 
occasionally,  even  muscular  effort  during  labor.  Sigru<. — Deformity,  pain, 
mobility,  etc.     Treat  like  a  broken  rib. 

Tibia,  Fracture  of. — When  the  shaft  of  this  bone  is  broken,  the  fibula 
remaining  entire,  the  deformity  is  almost  or  quite  nil,  and  other  symptom^ 
are  very  mild.  Trace  ridge  of  shin  carefully  with  forefinger.  Best  treal- 
vient,  a  plaster  case.  Separation  of  upper  epiphysis  may  cause  arrest  of 
growth.  Fracture  of  internal  inialleolus  is  generally  combined  with  dislo- 
cation of  foot  inward  or  outward,  quod  vide. 

Tibia  and  Fibula,  Fracture  of  {Fracture  of  Leg). — Commonest  Situa- 
tion.— Junction  of  middle  and  lower  third.  Causes. — Violence,  direct 
or  indirect,  sometimes  slight.  Kara  in  children.  Sigiis. — Typical  and 
unmistakable.  Deformity. — Upper  fragment  projects  forward  and  in- 
ward in  most  cases.  Tendency  to  eversion  of  foot  (as  in  almost  all  frac- 
tures of  lower  extremity).  Treatment. — Handle  carefully  and  set  at  once, 
because  of  danger  of  converting  simple  into  compound  fractui-e,  through 
sharp  end  of  upper  fragment  piercing  skin.  Set  with  great  toe  in  line 
with  inner  border  of  patella,  so  that  recovery  may  not  take  place  with 
eversion  of  foot.  Keep  straight  the  line  of  the  anterior  border  of  the 
tibia.  Anaesthetize,  if  necessary.  Division  of  tendo  Achillis  perhaps  re- 
quired in  rare  cases.  Apparatus. — 1.  Starch  bandage  and  miU-board, 
plaster-of-Paris,  Bavarian  splint,  or  some  other  fixed  apparatus.  See  gen- 
eral article  on  Fractures,  above.  2.  Cline's  splints  (common  lateral  ones 
with  foot-pieces).  3.  Fracture-box,  i.e.,  two  plain  side-splints  with  back- 
piece  furnished  with  foot-board.  4.  Mclntyre's  splint.  5.  When  there  is 
much  tendency  to  antero-posterior  displacement,  laying  limb  on  its  outer 
side,  with  knee  and  hip  flexed,  is  often  successful.  6.  Anterior  wire-sj^lint. 
With  most  of  these  apparatus,  some  form  of  swing  may  be  advantageously 
used.  Keep  foot  at  right  angles  to  leg.  Duration  of  treatment,  usually 
five  weeks  before  patient's  limb  may  be  ti'usted  in  a  mere  light  gum  and 
chalk  case. 

Compound  Fracture  of  Leg. — Two  kinds :  firstly,  when  a  fragment 
pierces  a  moderate  wound  in  skin  from  within  outward  ;  secondly,  when 
the  wound  is  very  large,  or  when  it  is  produced  by  severe,  crushing,  exter- 
nal violence.  Practically,  most  cases  can  be  thus  classed,  and  the  latter 
are  veiy  much  more  serious  than  the  former.  Do  not  attempt  to  do  what  is 
called  "close  the  wound,  and  convert  it  into  a  simple  fracture."  If  the 
case  is  slight  enough,  you  will  not  be  able  to  prevent  it  from  closing  it- 
self, unless  you  are  meddlesome.  Support  the  whole  limb  by  plaster  band- 
aging over  a  layer  of  cotton  wool,  and  immediately  over  the  wound  and 
its  neighborhood  apply  oakum,  to  absorb  all  discharge.  Protect  skin  and 
woimd  from  irritation  of  tar  in  oakum  by  greasing  with  zinc  ointment ; 


98  GANGLION. 

or  use  Lister's  antiseptic  treatment.  So-called  "open  treatment"  is 
scarcely  more  open  as  regards  the  wound  than  a  thick  layer  of  porous  and 
absoi-ptive  material  like  oakum  ;  though,  of  course,  it  is  open  enough  to 
noxious  influences  floating  about  the  sick-room.  But  it  is  only  just  to 
say  that  the  "  open  treatment "  has  had  excellent  results  under  Humphry 
and  others.  Hemorrhage  can  almost  always  be  restrained  by  pressure.  For 
complications,  erysipelas,  abscess,  pyi^mia,  etc.,  see  articles  on  those  subjects. 

Ulna,  Fracture  of. — Thi'ee  kinds — 1,  shaft ;  2,  olecranon  ;  3,  coronoid 
process.  Shaft. — Treat  like  fractiire  of  shaft  of  radius.  Fracture  of  Ole- 
cranon.—  Causes. — Falls  on  elbow  ;  rarely  muscular  violence.  Signs. — 
Swelling,  ecchymosis,  and  tenderness.  Fragment  drawn  up  by  triceps. 
Treatment. — Anterior  splint,  thickly  padded  in  bend  of  elboAv,  so  that  the 
limb  may  be  slightly  flexed.  Passive  motion  in  fifth  week.  Besult. — 
Union  often  ligamentous.  Fraxiture  of  Coronoid  Process. — Excessively  rare. 
Ulna  dislocated  backward  from  trochlea,  easily  reduced,  but  slips  back 
again  directly.  Treatment. — Posterior  angular  splint,  straight  splint  in 
front  of  humerus. 

Frost-Bite. — Frost-bites  vary  in  degree  as  much  as  burns  and  scalds. 
Signs. — In  severe  cases :  tingling,  numbness,  coldness,  stiffness,  white  or 
mottled  appearance.  Reaction  is  accompanied  by  inflammatory  symptoms, 
and  by  gangrene  in  the  severer  cases.  The  gangrene  may  be  either  im- 
mediate, when  it  will  be  of  the  dry  variety,  or  secondary  to  the  inflam- 
matory symptoms,  when  it  will  be  moist.  Treatment. — Resembles  that  of 
burns ;  but  the  greatest  care  is  required  in  restoring  circulation  to  the 
frost-bitten  part.  Cold  room,  friction  with  snow,  or  cold  flannel  or  fur. 
Stringently  avoid  hot  water,  fires,  etc.  In  those  cases  where  persons  ex- 
posed to  cold  are  overcome  with  sleep,  they  should  not  be  suddenly  carried 
into  a  warm  atmosphere.     Use  friction  and  gradual  warmth. 

Ganglion. — Two  kinds,  simple  and  compound.  Simple  is  said  to  arise 
from  a  cystic  enlargement  of  a  cell  in  one  of  the  fringes  of  synovial  mem- 
brane lining  the  sheath  of  the  tendon  (Paget),  and  it  is  also  said  to  be 
originally  a  partial  "  hernia  "  of  the  sheath  of  the  tendon  (Billroth).  Any 
way  it  is  rarely  found  communicating  with  the  tendon-sheath  at  all.  It  is 
a  fibrous  sac,  containing  a  fluid,  usually  jelly-like,  sometimes  quite  serous 
in  consistence.  Situation. — Most  frequently  over  extensor  tendons  at  back 
of  radial  side  of  wrist.  Apjjearrnce,  globular,  hard  or  fluctuating,  trans- 
parent swelling.  It  causes 'feeling  of  weakness  and  often  pain.  Treatment. 
— 1.  Rupture.  Place  patient's  wiist  on  your  knee,  then  steady  it  with 
your  fingers,  while  you  squeeze,  with  ends  of  both  your  thumbs,  the  gan- 
glion against  a  ridge  of  bone,  beneath  it.  2.  Iodine  paint  or  blistering.  3. 
Pressure.  4.  Subcutaneous  puncture.  Follow  up  both  1st  and  4th  method 
of  treatment  with  pressure  by  pad  and  bandage. 

CoMPOxrai)  Palmar  Ganglion  is  a  dilatation  of  a  considerable  part  of  a 
tendon-sheath,  or  of  several  tendon-sheaths.    Situation. — Pahn  of  hand  and 


GANGEENE.  90 

lower  part  of  forearm  just  above  annular  ligament.  Similar  compound 
ganglia  occasionally  found  in  foot.  Signs. — Fluctuating  swelling  above 
and  below  anterior  annular  ligament ;  crackling  from  melon-seed  bodies 
usually  contained  within.  Treatment. — 1.  Puncture  with  a  trocar  large 
enough  to  let  melon -seed  bodies  pass  through  its  canula.  Wash  away 
these  bodies  by  injection  with  warm  water.  Inject  tinct.  iodini,  3  iss.  -|-  aqua* 
§  iss.  Let  injection  escape  after  two  minutes.  Then  apply  compress,  splint, 
and  bandage.  2.  Incisions  above  and  below  annular  ligament.  These 
should  be  longitudinal.  Antiseptic  dressing  very  ad^'isable.  Gently  re- 
move melon-seed  bodies  by  syringing  with  weak  carbolic  lotion. 

Gangrene. — The  term  signifies  the  death  of  a  part  of  the  soft  tissues 
of  the  body.  The  dead  part  is  called  a  "  slough,"  and  the  term  "sloughing" 
is  often  applied  indifferently  to  the  diseased  action  which  results  in  the 
slough  and  to  the  reparative  process  by  which  the  slough  is  afterward  cast 
off.  Varieties. — Two  main  classifications:  1,  into  (ir;/ and  inoist ;  2,  into 
traumatic  and  idiopathic.  Causes. — A.  Of  traumatic  gangrene  :  1,  mechanical 
violence,  e.g.,  crushing  and  disintegrating  action  of  a  cart-wheel  passing 
over  a  limb ;  2,  mechanical  pressure,  e.g.,  bed-sore,  and  strangulation  of  a 
limb  by  a  tourniquet;  3,  chemical,  e.g.,  the  effects  of  corrosive  acids,  or 
excessive  heat  or  cold,  or  of  extravasated  urine.  B.  Idiopathic  gangrene 
has  for  its  remote  causes  the  following :  1,  general  anaemia,  e.g.,  gangTene 
has  been  known  to  foUow  excessive  venesection  ;  2,  arterial  obstruction  from 
embolism  or  thi'ombosis  in  cases  of  atheroma — this  form  usually  occurs  in  old 
people,  and  is  called  senile  gangrene  ;  3,  specific  fevers  and  their  sequeLn?, 
especially  typhus,  typhoid,  and  septicaemia  ;  4,  certain  diseases,  mostly  inflam- 
matory, e.g.,  carbuncle,  phagedoena,  etc.  ;  5,2yoisons  inoculated  or  swallowed, 
e.g.,  ergot  of  rye,  serpent's  poison,  etc.  Certainly  many  of  the  above  causes, 
and  probably  all,  act  either  by  diminishing  the  supply  of  blood  to  the  part, 
or  by  obstructing  its  escape  from  the  part,  or  by  both  ways  combined. 
Gangi'ene  produced  purely  by  diminished  blood-supply  is  dry  ;  that  caused 
partly  or  wholly  by  obstructed  return  of  blood  is  moist.  Inflammation  is 
an  aggravating  element  in  most  cases  of  gangrene,  and  an  essential  element 
in  many.  Two  or  more  of  the  above  causes  are  frequently  combined  ;  e.g., 
senile  gangrene  results  often  from  a  wound  of  the  toe  of  an  old  person 
with  atheromatous  arteries.  Pathology  may  be  inferred  to  a  great  extent 
from  what  has  been  said  above  concerning  the  causes,  and  what  will  be 
said  below  about  the  symptoms.  The  appearances  are  primarily  those  of  a 
region  where  the  vessels  are  either  almost  empty  or  else  distended  with 
stagnant  blood.  Then,  in  the  part  itself,  if  blood  can  pass  through  it  at 
all,  but  always  in  its  immediate  neighborhood,  inflammation  occurs.  Now, 
if  the  part  is  exposed  to  the  air,  it  next  begins  to  decompose,  and  one 
should  notice  that  most  of  the  so-called  appearances  of  gangrene,  e.g.,  foul 
odor,  are  really  signs  of  putrefaction  in  the  gangrenous  tissues.  For  a  time, 
the  inflammatory  and  gangrenous  process  spreads.     When  it  reaches  its 


1 00  GANGRENE. 

limits,  the  inflammation  on  its  borders  produces  granulations  between  the 
liA'ing  and  dead  regions,  which  granulations,  as  it  were,  push  oS  the  dead 
structures.  In  gangrene  of  emboHc  origin,  emboH  are  found  in  the  arteries. 
The  Hne  where  the  gangrenous  process  stops  and  the  wall  of  granulations 
is  formed,  is  called  the  line  of  demarcation. 

Symptomfi  and  Course. — 1.  Dry  gangrene.  First  appearance  often  a 
brown  spot  on  one  toe  ;  this  spreads,  the  parts  affected  gradually  shrivelling 
up,  the  skin  wrinkling,  and  becoming  brownish  black.  This  process  is 
called  "mummification."  2.  Moist  gangrene  begins  with  signs  of  inflam- 
mation. Then  the  SAvelling  becomes  boggy,  skin  mottled  or  violet.  Bullae. 
Discoloration  spreads  and  deepens.  Local  insensibility.  Fall  of  tempera- 
tui'e  locally.  Emphysematous  crackling.  Foul  odor.  Extent  of  process 
varies  from  part  of  toe  to  a  whole  limb.  Either  of  above  series  of  symptoms 
observed  in  senile  gangrene.  Traumatic  gangrene  is  always  more  or  less 
moist  and  inflammatoiy.  If  patient  survives,  the  dead  parts  are  cast  off  in 
the  way  described  above  {Pathology),  the  tendons  and  fasciae  giving  way 
last  but  one,  and  the  bone  absolutely  last.  Process  of  spontaneous  separation 
of  any  segment  of  a  hmb  occupies  months.  Constitv.lional  Symptoms. — In 
traumatic  gangi-ene,  those  of  great  prostration  and  fever  of  a  low  type. 
In  senile  gangrene,  they  may  be  yerj  slight,  but  usually  they  are  those 
of  chronic  septicaemia,  viz.,  gradual  exhaustion,  feeble  pulse,  dry  tongue,  ner- 
vous sensibility  dulled,  etc.  Diagnosis. — Gangrene  must  be  distinguished 
from  ecchymosis  caused  by  blows,  and  from  lividity  the  result  of  exposure 
to  cold.  Prognosis. — Bad,  unless  part  affected  is  small  or  a  line  of  de- 
marcation has  formed.  Worse  when  from  constitutional  than  when  from 
purel}'  local  causes. 

Treatment. — When  only  a  small  part,  e.g.,  the  end  of  a  finger,  is  affected, 
and  when  the  cause  is  traumatic,  treatment  is  purely  local,  otherwise  it  is 
also  constitutional.  Local  treatment. — Two  objects  :  1,  to  promote  de- 
tachment of  the  gangrenous  parts  ;  2,  to  prevent  the  gangrenous  parts 
from  decomposing,  and  thus  infecting  the  patient  and  his  chamber  or 
ward.  Use  absorptive  compresses  of  tow  or  oakum,  wet  with  chlorine 
water,  carbolic  lotion,  etc.,  but  not  too  wet.  Charcoal  powder.  Iodoform. 
Never  drag  off'  sloughs.  Remove  them  gently  when  they  are  fully  formed. 
After  separation  of  dead  parts,  treat  like  an  ordinary  granulating  wound. 

Question  of  Amputation. — It  is  a  verj'  safe  rule  in  civil  practice  never  to 
amputate  till  a  line  of  demarcation  has  formed.  Leave  single  toes  to  fall 
off.  "If  the  whole  foot  or  leg  be  affected,  do  the  amputation  so  that  it 
may  be  merely  an  aid  to  the  normal  process  of  detachment ;  i.e.,  on  the 
borders  of  the  healthy  parts  you  tiy  to  dissect  up  only  enough  skin  to 
cover  the  stump,  and  saw  the  bone  as  near  as  practicable  to  the  line  of  de- 
marcation "  (Billroth). 

Constitutional  Treatment. — Relieve  pain  with  opium  (up  to  gr.  ^  every 
three  hours)  or  morphia,  subcutaneously.     If  these  disagree,  use  chloral 


GASTEOTOMY.  101 

(gr.  XX.  6""  horis)  or  some  other  anodyne.  Watch  their  effect  well.  Extent 
to  which  you  give  or  withhold  stimulants  and  nourishment  dejjends  on 
relative  importance  you  attach  to  remediable  weakness  and  inflammation 
respectively,  as  factors  in  extending  the  gangrene.  Nourishing  fooJ, 
quinine,  acids,  gentian,  camphor,  or  ammonia,  are  used  as  a  rule  ;  but 
Syme  declared  that  in  senile  gangrene  he  got  the  best  results  from  com- 
paratively low  diet. 

Prophylaxis. — For  gangrene  threatening  fi-om  excess  of  tension,  use 
free  incisions.  Gangrene  from  arterial  obstruction,  local  warmth.  Gangrene 
from  venous  obstruction,  elevation  of  limb,  support  by  gentle,  even 
bandaging. — See  also  Bed-Sores.  In  severe  crushes,  where  gangrene  seems 
inevitable,  it  is  better  to  amputate  before  reactionary  fever  has  set  in,  unless 
indeed  the  limits  of  the  pai'ts  hopelessly  injured  cannot  be  sufficiently 
made  out. 

Gastrotomy. — A  term  applied  to  two  distinct  operations,  viz.:  1, 
opening  the  stomach  ;  2,  opening  the  abdominal  cavity  only. 

Gastrotomy,  or  operation  of  making  opening  into  stomach.  Called 
"  gastrostomy  "  when  done  for  disease  of  the  oesophagus.  Indications. — 1. 
"When  a  foreign  body  has  entered  the  stomach,  and  cannot  safely  either 
pass  through  the  pylorus  or  be  vomited  or  extracted  by  the  mouth.  2. 
When  an  impervious  stricture  of  the  oesophagus  is  of  traumatic  origin. 
Indication  is  then  imperative.  3.  In  cases  of  cancer  of  oesophagus.  In 
these,  though  death  has  always  speedily  followed  operation,  yet  patient's 
sufferings  have  been  much  relieved.  Prognosis. — Usually  followed  by 
speedy  death  when  done  for  disease  of  the  oesophagus,'  but  very  safe  (1 
death  in  11)  when  done  for  foreign  body.  In  former  case,  death  is  more 
from  advanced  disease  than  from  operation.  Operation. — Scalpel,  forceps, 
hgatures,  director,  hooks,  catch-forceps,  retractors,  handled  needles,  silk 
ligatures,  bits  of  bougie  for  quUled-suture.  Incision,  curved  for  4  inches, 
just  internal  to  edge  of  left  costal  cartilages,  from  sternal  extremity  of 
seventh  intercostal  space,  downward  and  outward.  Divide  successive  layers 
on  a  director.  Edge  of  left  lobe  of  liver  may  be  useful  as  guide  to  stomach. 
Pull  stomach  out  with  finger  and  thumb.  When  quite  certain  of  having 
got  the  right  viscus,  seize  it  with  catch-forceps,  if  gastrostomy  is  to  be 
done.  Two  double  ligatures  from  side  to  side  through  lips  of  wound  and 
wall  of  stomach.  Open  viscus.  Pull  ligature  loops  out  of  wound  and  di- 
vide them.  Quills  inside  and  out.  Additional  sutures  at  corners  of  wound. 
Unless  patient  is  much  exhausted,  feed  by  enemata  only  for  first  twenty- 
four  hours  at  least.  When  operating  to  remove  foreign  body,  make  open- 
ing in  stomach  small,  and  sew  up  with  continuous  sutui*e  unless  opening 
spontaneously  closes. 

'  Two  successful  cases  :  Verneuil's,  see  Lancet,  January  I'l,  1877  ;  and  Stanton's, 
see  Medical  Press  and  Circular,  December  39,  1880.     Both  were  dressed  antisepticaliy. 


102  GONOERH(EA. 

Gleet. — See  Gonoerhcea. 

GlioiTia. — See  Tumoes,  Sakcomatous. 

Glottidis,  CEdema. — See  Laryngitis. 

Goitre. — See  Bkonchocele. 

Gonorrhcea. — Definition. — Inflammation  of  mucous  membrane  of  male 
urethra  or  of  female  genitals,  following  impure  sexual  intercourse.  I  have 
worded  the  definition  as  above,  because,  in  practice,  one  applies  the  term 
gonorrhoea  to  any  urethritis  following  impure  intercourse,  whether  there  be 
specific  contagion  or  not.  Causes. — 1.  Specific  infection  by  contact  with 
gonorrhceal  or  gleety  secretion.  2.  Irritation  or  infection  by  non-specific 
secretion  from  a  diseased  mucus  surface  (?).  Symptoms  and  Course. — Four 
stages.  1.  Premonitory. — Itching,  swelling,  and  stickiness  of  meatus :  oc- 
curs about  two  to  seven  days  after  intercourse,  and  lasts  twenty-four  hours, 
more  or  less.  2.  Inflammatory. — Scalding,  discharge  of  pus,  painful  erec- 
tions, chordee,  tenderness  along  urethra,  or  confined  to  part  actually  in- 
flamed. Occasionally  spasmodic  retention.  Glans  and  prepuce  swollen  : 
sometimes  phimosis  or  paraphimosis.  Duration  one  week  to  one  month. 
3.  Inflammation  passes  gradually  away,  but  a  thick  discharge  remains.  4. 
When  only  a  thin  serous  discharge  remains,  called  gleet.  Pathology. — Red- 
ness, sweUing,  etc.,  of  mucous  membrane  of  urethra.  Occasionally  slight 
excoriation  or  ulceration.  Micrococci  and  vibriones  have  been  found  in 
gonorrhceal  pus,  and  perhaps  infest  the  inflamed  membrane  itself.  Parts 
chiefly  affected,  fossa  navicularis  and  bulbous  part.  Cause  of  chordee,  ef- 
fusion of  lymph  into  corpus  spongiosum,  which  effusion  prevents  lower 
border  of  penis  from  extending  proportionally  during  erection.  Complica- 
tions.— Bubo,  balanitis,  phimosis,  paraphimosis,  hemorrhage,  cutaneous 
rash,  gonoiThceal  rheumatism,  epididymitis,  cystitis,  prostatitis,  retention 
of  urine,  chordee.  All  but  chordee  are  noticed  in  separate  articles.  Treat- 
ment.— Local  and  genei'al. — Local  is  effected  by  (1)  injections  ;  (2)  soluble 
bougies  of  cacao  butter  (Sir  H.  Thompson  and  IVIr.  W.  T.  Cooper  ')  or  of 
"ice"  (Abrath);  (3)  insoluble  bougies,  e.g.,  wax,  ivory,  etc.;  (4)  clay 
bougies  (Chiene);  (5)  powders  insufflated  (Wilders,  Lancet,  vol.  i.,  p.  73). 
There  are  also  external  local  applications,  such  as  cold  sitz-bath,  ice  to 
perinaeum,  blisters  (Milton),  etc.  Rules  for  Injecting. —  Pass  the  nozzle 
into  the  urethra,  right  up  to  the  hilt,  and  press  it  home.  Hold  the  glans 
close  up  to  it  with  the  left  finger  and  thumb.     Inject  slowly  about  half  a 

'  As  cacao-butter  bougies  melt  as  soon  as  they  enter  the  urethra,  they  differ  little 
from  a  thick  fluid  injection.  They  have  these  advantages,  that  they  are  sure  to  enter 
the  urethra,  and  that  they  remain  there,  but  they  do  not  distend  the  urethra,  as  a 
properly  administered  fluid  injection  does,  for  several  minutes.  A  soft  and  flexible 
bougie  which  will  slightly  distend  the  urethra  as  long  as  may  be  desired  can  be  made 
as  follows  :  Roll  a  square  piece  of  antiseptic  gauze,  like  a  pipe-light,  dip  it  into  medi- 
cated cacao-butter,  or  into  medicated  vaseline  thickened  by  mixing  with  sperm  or  firm 
paraffin.     Use  for  gleet  only. 


GONORRHCEA.  103 

drachm.  (There  need  be  little  or  no  fear  of  mischief  from  an  ordinary  in- 
jection entering  the  bladder.  It  is  unlikely  to  get  so  far  at  all.)  Retain 
the  injection  three  to  five  minutes  if  possible.  In  most  cases  inject  after 
each  urination.  Injections. — As  a  basis,  "  strong  "  tragacanth  mucilage  is  ^ 
excellent.  It  will  remain  in  the  urethra  all  night.  The  many  urethral  in- 
jections which  have  been  used  successfully  may  be  classed,  more  or  less 
accurately,  as  (1)  antiseptics,  (2)  astringents,  (3)  sedatives,  (4)  cleansing. 
Antiseptics:  iodoform  (gr.  xxx.  to  tragacanth.  emuls.,  3  j.),  carbolic  lotion 
(1  to  40),  permanganate  of  potash  (gr.  j.  to  3  x.),  chloralum  (gr.  iij.  to  3  j.), 
borax  (gr.  v.  to  |  j.),  zinci  chlor.  (gr.  j.  to  3  j.).  With  these  might  be  classed 
also  solutions  of  iodine,  chlorate  of  potash,  and  many  also  of  the  astringent 
injections,  which  are  both  astringent  and  antiseptic.  Glycerine  is  con- 
stantly combined  with  injections  of  all  kinds,  and  its  value  jDossibly  lies  in 
its  power  of  checking  fermentative  changes.  Secondly,  astringent  injec- 
tions :  tannic  acid  (gr.  v.  to  3  j.),  zinci  suljoh.  (gr.  ij.  to  3  j.),  zinci  sulj)ho-car- 
bolat.  (gr.  ij  to  |  j.),  zinci  acet.  (gr.  ij.  to  3  j.),  plumbi  acet.  (gr.  ij.  to  3  j.),  ar- 
gent, nit.  (gr.  i  to  3  j.).  Also  solutions  of  kino,  catechu,  and  eucalyptus  gum. 
Thirdly,  sedative  injections  :  sedatives  are  almost  always  used  in  combina- 
tion, e.g.,  liq.  morph.  acet.,  TTl.  x. ;  glycerini  acidi  tannici.  Til,,  xx. ;  aquae ,  3  j.  ^ 
Fourtlily,  cleansing  injections,  such  as  warm  water,  used  in  very  acute  gon- 
orrhoeas. Many  excellent  injections  are  combinations.  Such  a  one  is  the 
French  injection  of  M.  Brou,  containing  probably  calamine,  opium,  and 
some  vegetable  decoction.  Powders,  such  as  zinci  oxid.,  in  suspension, 
are  believed  to  cling  to  the  urethral  surface. 

Soluble  bougies  can  be  medicated  with  any  of  the  above  substances. 
It  is  customary  to  place  a  piece  of  lint  or  cotton -wool  over  the  meatus  after 
passing  the  bougie,  and  to  fix  it  with  strapping. 

Insoluble  bougies  are  sometimes  dipped  in  an  active  agent,  sometimes 
used  unmedicated,  for  gleet.  » 

Modifications  in  Treatment  according  to  the  Stage  of  the  Disease. — First 
stage.  "Abortive  Treatment."  Rest  as  much  as  possible;  at  all  events 
avoid  fatigue.  Moderate  diet.  No  stimulants.  Frequent  cold  hip-baths  ; 
saline  purgatives  ;  alkaline  and  demulcent  drinks  ;  acetate  of  potash  ;  weak 
astringent  and  antiseptic  injections  repeated  as  often  as  possible  (acid, 
tannic,  gr.  v.  ;  glycerini,  V\.  xx.  ;  aqu^,  3  j.).  Second  stage.  General  treat- 
ment same  as  first  stage.  But  be  more  cautious  about  introducing  irri- 
tants into  the  urethra.  Treat  complications.  For  chordee  :  belladonna 
extract  along  outside  of  corpus  spongiosum,  morphia  and  henbane  sui:)po- 
sitories  ;  warm  baths  ;  sleeping  draught  at  night.  Sp.  camjih.,  3  ss.  doses, 
internally.  One  minim  of  tinct.  aconiti  every  hour  will  sometimes  cut 
short  this  stage.  Third  stage.  Still  prohibit  stimulants  and  avoid  fa- 
tigue. Persevere  with  injections  ;  vary  them  if  the  case  be  obstinate.  For 
use  of  copaiba,  etc.,  see  below.  Fourth  stage  (that  of  gleet).  Continue  in- 
jections and  general  treatment,  but  improve  diet.     Change  of  air.     Tonics, 


104  GONORKHCEA. 

e.g.,  iron,  quinine,  strychnia,  gentian,  etc.  But  gleet  is  so  often  kept  up 
by  a  slight  stricture,  that  it  is  imperative  to  examine  weU  the  urethra  in 
obstinate  cases,  and  to  dilate  it  if  necessary.  It  is  a  good  nile,  in  treating 
gonorrhoea,  to  inject  after  every  act  of  micturition.  Persons  away  from 
home  aU  day  should  use  the  compressible  metal  tubes,  filled  with  injection, 
and  having  a  nozzle  to  enter  the  urethra,  made,  at  my  request,  by  Mr. 
Cooper,  of  26  Oxford  Street.  They  should  be  carried  in  the  coat  side- 
pocket.  Mr.  Watson-Cheyne  urges  that,  in  treating  a  gonorrhoea,  the  first 
thing  to  aim  at  should  be  the  destruction  of  the  specific  nature  of  the  dis- 
ease. To  effect  this  he  recommends  a  bougie  (iodoform,  gr.  v.  ;  ol.  eucalypti, 
gr.  v.  ;  ol.  theobromae,  q,  s.).  Patient  passes  the  bougie,  and  Hes  down  for 
six  hours.  Follow  up  with  injections  of  emulsion  of  eucalyptus  oil  till  a 
slight  simple  urethritis  remains.  Then  resort  to  some  ordinary  astringent 
injection.  The  chief  difficulties  in  curing  a  gonon-hoea  ai-ise  fi-om  the  dis- 
obedience or  impatience  of  the  patient,  who  relaxes  his  attention  to  his 
disorder  as  soon  as  it  begins  to  improve,  whereas  he  ought  to  persevere 
with  the  treatment  even  for  a  week  after  the  disease  is  appai-ently  quite 
cured.  Within  that  period,  even  half  a  glass  of  claret  may  cause  a  relapse. 
The  following  i-ule  is  of  prime  importance.  The  surgeon  should  teach  the 
patient  how  to  inject.  He  should  administer  the  first  injection  himself  ; 
and,  if  it  be  effectively  done,  this  first  injection  may  strike  the  death-blow 
of  the  gonorrhoea.  A  suspensory  bandage  should  be  worn  as  a  prophylactic 
against  epididymitis.  The  ordinary  one  is  often  quite  useless.  The  band- 
age made  by  Messrs.  Ai-nold,  of  West  Smithfield,  should  be  used.  To 
absorb  the  discharge,  and  keep  the  linen  clean,  an  excellent  application  is 
a  thin  layer  of  absorbent  cotton-wool,  stuck  to  gutta-percha  tissue,  and  tied 
to  the  penis  by  a  piece  of  tape.  Chastity  is  necessary  in  the  first  three 
stages.  Gleet  is  not  always  infectious,  but  abstinence  fi'om  intercoiu-se  is 
desirable  even  during  this  stage. 

Copaiba,  Cubebs,  and  Oil  of  Sandal  Wood. —  Copaiba  not  advisable 
in  the  acute  stage,  cubebs  best  in  first  stage,  oil  of  sandal  wood  good  for 
any  stage.  Dose  of  copaiba,  2  capsules  three  or  four  times  a  day,  or  3  gr. 
of  the  balsam  made  into  an  emulsion  with  yolk  of  egg,  or  floating  on  infu- 
sion of  roses,  three  times  a  day.  Dose  of  cubebs:  a  heaped  teaspoonful 
four  times  a  day  mixed  with  soda-water.  Cubebs  and  copaiba  together  ; 
make  the  cubebs  up  into  jjills  Avith  copaiba  balsam  and  white  wax,  and 
give  ten  pills  three  times  a  day.  Dose  of  sandal  wood ;  tti,.  xv.,  ter  die. 
I^.  01.  santalini,  3  ss.;  sp.  viui  rect.,  §  iss.  M.  ft.  mist.  S. —  3  j-  ex  aquee. 
f  j.,  ter  die. 

Copaiba  rash  is  papular,  and  sometimes  resembles  urticaria,  sometimes 
measles  ;  but  there  is  no  fever,  and  the  r9,sh  is  patchy,  chiefly  affecting 
skin  over  joints.     Warn  patients  of  danger  of  gonorrhoeal  ophthalmia. 

GoNOEKHffiA  IN  Female.  —  Par/s  affected. — "Vagina  and  vulva.  Disease 
may  spread  considerably,   even  up  urethra  to  bladder,  and,   it  is  said, 


GUNSHOT    WOUNDS.  105 

through  Fallopian  tubes  to  peritoneum.  Other  complications  are  bubo, 
labial  abscess,  and  warty  growths.  Less  common  are  metritis  and  ovaii- 
tis.  Treatment. — Main  special  points  are,  to  use  large  quantities  of  weak 
injections  pumped  freely  into  vagina,  to  insert  a  piece  of  clean  lint  be- 
tween the  labia  after  each  injection,  and  to  prescribe  rest,  both  local  and 
general. 

Groin,  Chief  Surgical  Diseases  of. — See  table  in  Holmes's  "  Sys- 
tem," vol.  v.,  p.  999.  1.  Psoas  abscess ;  2,  glandular  abscess ;  3,  abscess 
from  diseased  hip  ;  4,  simple  abscess  ;  5,  enlarged  glands ;  6,  cysts ;  7,  en- 
cysted hydrocele  ;  8,  common  hernia  ;  9,  incarcerated  hernia  ;  10,  strangu- 
lated hernia ;  11,  retained  testis  ;  12,  vaiix  of  saphena  vein  ;  13,  aneurism  ; 
14,  malignant  disease  ;  15,  other  tumors.  Of  these,  hernia  alone  is  sometimes 
resonant  on  percussion.  Common  hernia  and  varix  of  saphena  are  alone 
completely  reducible.  Psoas  abscess,  encysted  hydi'ocele,  and  retained 
testis  are  or  may  be  partly  reducible.  Abscesses,  cysts,  varix,  and  aneur- 
ism may  fluctuate.  Abscesses  (excepting  psoas),  inflamed  glands,  and  in- 
flamed aneurism  show  heat,  redness,  etc.  Impulse  on  coughing  may  be 
found  in  hernia  and  psoas  abscess,  and,  much  more  rarely,  in  cysts, 
strangulated  hernia,  retained  testis,  and  some  tumors.  Holmes's  table  is 
worth  committing  to  memory. 

Gums  are  affected  by  abscess  (so-called  gum-boil),  by  ulceration,  and 
by  hypertrophy.  Abscess  arises  from  irritation  of  carious  tooth.  Foment ; 
open  when  abscess  has  fairly  formed  ;  attend  to  teeth.  Ulceration  is  caused 
by  mercui-y,  scurvy,  syphilis,  and,  indeed,  any  other  cause  of  stomatitis. 
Remove  cause.  Wash  with  pot.  chlorat.;  paint  with  sol.  argent,  nit.,  gr. 
X.  to  I  j.,  or  touch  with  soHd  argent,  nit.  Tonics  and  pot.  chlorat.  inter- 
nally.    Hypertrophy  may  require  outgrowth  to  be  snipped  off. 

Gunshot  Wounds. — Belong  to  the  class  of  contused  wounds.  Causes. 
— 1,  Mere  explosions  of  powder  ;  2,  wadding  ;  3,  small  shot ;  4,  buUets 
and  slugs  ;  5,  cannon-balls  ;  6,  spHnters  of  shells. 

Pathology  and  symptoms  are  most  conveniently  described  together 
under  the  head  of  Characters. — Four  chief  forms  of  gunshot  wound,  viz.: 
1.  Simple  contusions,  caused  by  spent  shot,  or  by  "oblique  impact." 
Formerly  attributed  to  "  windage."  May  produce  most  severe  internal 
injirries  with  no  visible  damage  to  skin.  2.  Superficial  wounds,  gi'ooving, 
not  timnelling  the  flesh.  3.  Where  buUet  lodges.  Particles  of  clothing, 
etc.,  may  enter  with  it.  4.  Where  the  bullet  pierces  and  escapes.  Though 
bullet  escaj)e,  foreign  bodies  carried  in  with  it  may  remain.  Rifle-bullets, 
as  distinguished  from  musket-bullets,  make  cleaner  and  less  contused 
wounds,  but  smash  and  splinter  bones,  and  pierce  the  body  with  a  more 
straight  and  undeviating  course.  They  also  cause  greater  shock.  Shock. 
— Depends  much  upon  individual  constitution.  Is  usually  great.  Pain 
usually  sHght,  often  unnoticed.  Hemorrhage. — Primary  is  rarely  serious, 
except  when  the  largest  vessels  are  wovmded.     Secondary  is  very  common, 


106  GUNSHOT    WOUNDS. 

perhaps  because  of  bad  sanitaiy  conditions  to  -wliicli  an  army  is  exposed. 
Burns  from  powder  may  occur  at  close  quarters.  Examination. — First  see 
how  many  wounds  there  are.  Then,  at  least  in  civil  practice,  examine  pa- 
tient's clothes.  Apertures  in  them  may  indicate  the  direction  of  the  wound  ; 
the  absence  of  a  piece  of  cloth  may  suggest  its  presence  in  the  wound  ;  or 
the  exit  of  the  bullet  may,  in  rare  cases,  be  proved  by  its  being  found 
in  the  clothes.  Then  explore  the  wound  with  the  finger  carbolized.  But 
in  gunshot  wounds  of  the  chest  or  abdomen,  the  sui-geon  should  insert 
neither  probe  nor  finger,  unless  he  is  prepared  to  follow  up  his  search,  if 
necessary,  by  operative  measures.  Place  the  patient  in  the  attitude  in 
which  he  received  his  wound  ;  its  dii'ection  can  thus  be  better  judged. 
Examine  carefully  once  for  all.  Counter -manipulation  with  the  fingers  of 
the  other  hand  to  assist  the  finger  in  the  wound.  Instruments  for  De- 
tection of  Bullets. — Nelaton's  probe  (porcelain  head).  De  Wilde's  electric 
bell  indicator.  lirohne  and  Sesemann's  electric  indicator.  Lecompte's 
stilet-pince,  which  bites  a  piece  off  the  supposed  bullet.  Objects  of  Exami- 
nation.— 1,  To  search  for  foreign  bodies  ;  2,  to  ascertain  direction  and  ex- 
tent of  wound  ;  3,  to  estimate  amount  of  injury  done  to  certain  parts,  e.g., 
fractured  bones. 

Apertures  of  Entrance  and  of  Eocit. — Former  is  cleaner  and  smaller  than 
latter,  smaller  even  than  the  ball  which  made  it.  Latter  is  everted  and 
larger  and  lacerated.  The  quicker  the  passage  of  the  ball  the  less  are 
these  differences  ;  and  they  are  sometimes  nil.  Only  part  of  a  bullet  may 
have  escaped  by  the  aperture  of  exit  if  a  bone  has  been  struck.  Or  a 
split  bullet  may  make  its  exit  in  two  places.  Bullet  may  rebound  from  a 
bone  and  fall  out  of  aperture  of  entrance.  Course  of  slow  bullets  some- 
times very  peculiar.  Healing. — 1.  Small  ring-shaped  slough  and  gangren- 
ous shreds  thrown  off.  2.  Granulation  and  suppuration.  Opening  of 
exit  usually  closes  before  that  of  entrance.  Prognosis. — Depends  entirely 
on  amount  and  position  of  injury.  "  The  extensive  tearing  and  crushing 
caused  by  large  missiles  do  not  differ  from  other  large  crushed  wounds 
caused  by  machinery."  Treatment. — Principles  of  treatment  same  as  those 
of  other  contused  wounds  ;  differences  of  detail  chiefly  depend  on  pecu- 
liarity of  surrounding  cix'cumstances. 

1.  In  battle,  check  hemorrhage  by  pressure,  apply  extemporized  splints 
to  fractured  limbs,  give  stimulants  in  case  of  syncope,  and  convey  patient 
to  place  of  first  dressing. 

2.  Apply  first  dressings  at  a  place  previously  selected.  Here  also  re- 
move all  foreign  bodies  that  are  near  the  surface,  and  amputate  limbs  hope- 
lessly crushed.  Attach  to  each  patient,  before  sending  him  on  from  here, 
a  card  with  short  account  of  his  case,  stating,  e.g.,  whether  ball  has  been 
extracted  or  a  wound  of  the  trunk  is  or  is  not  perforating.  Field  officers 
should  ligature,  if  possible,  every  wounded  vessel  of  importance  (Long- 
more). 


GUNSHOT    WOUJS^DS.  107 

3.  Convey  patient  to  hospital.  Here  examine  every  patient,  operate, 
dress  wounds,  bed,  and  diet.  Many  wounded  should  not  be  kept  collected 
in  one  place.  Extraction  of  Bullet. — Tiemann's  forceps.  Coxeter's  extractor. 
If  violent  measures  would  be  required  for  removal  of  bullet,  let  it  remain, 
unless  it  is  obviously  setting  up  irritation.  Dressing. — The  main  point  is 
not  to  actively  close  the  wound,  but  to  leave  free  room  for  the  discharge  to 
escape.     Tenax  and  oakum  very  good. 

Gunshot  Wounds  of  Special  Parts. — Head. — Very  dangerous,  from  the 
diffused  injury  done  to  the  brain  and  its  membranes.  Inner  table  fractiu-ed 
more  than  outer.  Frequent  complication  with  meningitis,  abscess,  etc. 
Gunshot  wound  of  brain  almost  always  fatal.  Fracture  with  depression 
usually  fatal.  r?'ea^mt;n^ —Perfect  rest,  darkness,  low  diet.  Cold  locally. 
Venesection  may  be  useful.  Trephining  contraindicated.  Do  not  mistake 
a  wound  in  which  part  of  outer  table  of  skull  has  been  ploughed  off  for 
fracture  with  depression. 

Thorax. — Classification,  diagnosis,  complications,  etc.,  much  the  same 
as  other  wounds  of  chest.  Non-penetrating  wounds  of  any  violence 
almost  sure  to  bruise  lung.  Penetrating  wounds  fatal  nine  times  out  of  ten. 
Treat  like  other  wounds  of  chest.  Allay  firstly  hemorrhage,  secondly  in- 
flammation. To  check  bleeding  from  an  intercostal  artery,  a  large  piece 
of  linen  is  laid  over  wound,  "  and  the  middle  portion  of  this  hnen  is  pressed 
into  the  wound  by  the  finger,  so  as  to  form  a  kind  of  pouch;  this  pouch 
is  then  distended  by  sponge  or  lint  pushed  into  it  until  the  pressiu'e  arrests 
the  bleeding ;  on  stretching  out  the  corners  of  the  cloth  the  pressui-e  of 
the  plug  will  be  increased  "  (Longmore). 

Abdomen — Kesemble  wounds  from  other  causes.  But  even  non-pene- 
trating wounds  often  fatal.  Penetrating  wounds.  Ball  may  pierce  more 
than  one  viscus.  The  chief  sign,  sometimes  the  only  sign,  of  penetration 
is  the  extreme  collapse.  Recovery  may  take  place  ;  then  often  a  fecal 
fistula.  Gunshot  wounds  of  bladder  have  often  recovered.  Proposal, 
in  case  of  injured  viscera,  to  open  the  abdomen,  search,  clean,  and 
suture. 

Extremities.  —Injuries  to  soft  parts  only,  usually  do  well,  unless  some 
large  artery  or  nerve  be  struck.  Injuries  to  hones  are  remarkable  for  com- 
minution, and  frequency  of  longitudinal  fissure  into  joints.  Consequent 
gi*eat  hability  to  osteomyelitis  and  blood-poisoning.  Impossible  to  be  so 
conservative  in  treatment  as  is  usual  in  civil  practice.  The  rule  is  to 
amputate  for  fractures  in  middle  and  lower  third  of  femur.  Put  up  most 
other  fractures  in  immovable  plaster  case.  In  gunshot  injuries  of  extremi- 
ties, as  of  other  parts,  ordinary  rules  of  surgery  apply,  only  bearing  in 
mind  the  smashing  and  splintering  and  the  special  difficulties  in  after- 
treatment.  Hence,  excision  of  knee  and  hip  condemned  by  experience. 
Shoulder,  elbow,  and  ankle  suitable  for  excision.  Put  up  excisions  in  im- 
movable plaster  cases.    In  some  cases  of  wounded  knee-joint,  an  attempt 


108  HEMOPHILIA. 

may  be  made  to  save  the  limb  ;  bere  again  a  plaster  case  is  necessary. 
Fractured  thighs  not  to  be  transported  far  to  hospital. 

Hsematocele. — Effusion  of  blood  into  tunica  -vaginalis.  Sometimes 
unnecessaiily  classified  into  trarmiatic  and  spontaneous.  Almost  always 
traumatic,  the  cause  being  a  blow  or  punctiu-e.  It  is  likely  that  hjematocele 
is  often  caused  by  a  rupture  of  a  varicosed  vein.  Slight  violence  is  in 
many  cases  sufficient  to  produce  this.  Witness  the  cause  of  IVIiss  Neilson's 
death — ruj)tured  varix  of  Fallopian  tube  diu'ing  an  attack  of  gastralgia. 
Hence  blood  escaped  into  peritoneal  cavity.  When  a  varicocele  ruptures, 
the  blood,  fortunately,  is  more  likely  to  enter  a  less  important  serous  sac, 
the  tunica  vaginahs.  Pathology. — Tunica  vaginalis  contains  blood,  which 
usually  remains  fluid,  only  becoming  gradually  darker  and  thicker  and  full 
of  fibrinous  shreds.  Sometimes  it  coagulates  more  or  less.  Tunica  vaginalis 
thickens.  At  any  period  inflammation  and  suj)puration  may  supervene. 
Symptoms. — Gradual  but  rapid  formation  of  a  smooth,  globular  or  pyri- 
form,  hai'd  or  semi-fluctuating,  non-transparent,  heavy  tumor.  Testicle 
situated  usually  below  and  behind ;  on  firm  jDressure  in  that  region,  the 
peculiar  testicular  pain  is  felt.  Mai'ks  of  bruising  may  appear  in  skin. 
Painless,  except  when  quite  recent.  Diagnosis. — Fi'om  1,  solid  innocent 
enlargement  of  testis ;  2,  sohd  malignant  tumor  of  testis ;  3,  hydrocele. 
Case  1.  Chronic  orchitis  begins  usually  with  acute  orchitis,  or  there  is  a 
history  of  syphUis  or  scrofula  ;  it  comes  on  more  gradually  than  hrema- 
tocele.  Case  2.  Cancer  begins  more  gradually,  but  enlarges  more  per- 
sistently, and  is  painful ;  liunbar  glands  enlarge  sooner  or  later  in  cancer. 
In  both  chronic  orchitis  and  cancer  thickening  of  cord  is  common.  Case 
3.  As  even  hydroceles  may  be  opaque,  unless  there  is  a  history  of  severe 
violence  followed  by  a  sudden  svyeUing  and  ecchymosis,  a  final  diagnosis 
cannot  be  made  without  the  trocar.  Prognosis. — Only  mild  and  recent 
cases  ofl:er  any  reasonable  hope  of  absorption.  Old  cases,  after  reaching  a 
certain  size,  usually  remain  stationary.  Inflammation  may  occur  at  any 
time.  Treatment. — 1.  When  hcematocele  is  recent.  Rest  in  bed,  applica- 
tion of  cold,  elevation  of  pelvis  and  scrotum.  2.  Later :  tap  with  trocar 
and  canula,  and  then  support  with  pressure.  3.  In  old  cases  with  thick 
walls,  or  in  any  case  when  suppuration  occurs,  incise  freely  and  empty. 
Do  this  antiseptically.  Operation  not  without  danger.  Hcematocele  of 
the  tunica  vaginalis  of  the  cord  occurs  but  very  rarely.  Symptoms,  etc., 
can  easily  be  inferred.     Blow  on  part,  ecchymosis,  swelling,  etc. 

Haematoma. — See  Tumors. 

Haematuria.— (See  Urine. 

Haemophilia. — Hemorrhagic  diathesis.  A  congenital  tendency  to 
free  bleeding  after  trifling  injuries,  or  even  no  injury  at  all.  Mostly 
hereditary.  Want  of  fi-esh  air,  of  dry-  lodging,  and  of  exercise  said  to  in- 
crease the  diathesis.  Attacks  males  more  than  females.  Symptoms  and 
CoMrse.— Bleeding  from  nose  and  mouth,  with  or  without  obvious  exciting 


HEMOEKHAGE.  109 

cause.  Spontaneous  ecchymosis  beneath  the  skin.  Bleeding  often  pre- 
ceded by  premonitory  symptoms,  such  as  vascular  excitement,  smell  of 
blood  in  nostrils,  and  pains  in  limbs.  In  intervals  of  hemorrhages,  joints 
swell  and  even  inflame.  Loss  of  blood  produces  antemia.  Pathology. — 
"Probably  abnormal  thinness  of  the  arterial  walls  "  (Billroth).  Frognosw. 
— Most  patients  die  young.  Some  seem  to  outlive  the  malady.  Treatment. 
— Employ  every  means  to  strengthen  general  constitution.  To  check 
hemorrhages  use  ordinary  means,  and,  in  addition,  in  serious  cases,  give 
sodse  sulphatis,  3  ss.,  occasionally,  and  two  to  five  grains  of  ergot  every 
half-hour.     Turpentine  in  di-achm  doses.     See  Legg  on  Haemophilia. 

Hemorrhage. — Hemorrhages  are  classified  in  several  ways,  viz., 
firstly,  according  to  their  soui'ce,  into  1,  arterial ;  2,  venous  ;  3,  capillary  ; 
and  4,  parenchymatous.  "  Parench^nnatous "  is  a  term  applied  by  the 
Germans  to  hemorrhage  from  the  tissues  full  of  small  arteries  and  veins, 
e.g.,  the  penis  and  the  tongue.  Secondly,  hemorrhages  are  classified,  ac- 
cording to  the  time  of  their  occiu'rence,  into  1,  primary  {i.e.,  at  time  of 
wound)  ;  2,  intermediate  or  recurrent  (Avithin  a  few  hours) ;  3,  secondary 
{i.e.,  a  few  days  after  wound).  A  third  classification  is  into  1,  traumatic; 
2,  spontaneous  {vide  Hemophilia).  Surgeon-Major  Porter  described  an 
intermittent  hemorrhage  from  malarial  influence.  Arterial  hemorrhage 
contrasted  with  venous  hemorrhage  :  Arterial  is  florid  and  spurts  in  jets  ; 
venous  is  dark,  and  either  does  not  spurt  rhythmically  at  all  or  does  so 
only  in  relation  with  the  acts  of  respiration.  Arterial,  however,  is  dark  when 
respiration  is  interfered  with  ;  and  venous  is  florid  sometimes,  when  it  wells 
up  from  a  deep  wound  and  is  thus  exposed  to  the  air  before  becoming  visi- 
ble. Natural  Checks  to  Hemorrhage. — Arterial  hemorrhage  is  stopped  natu- 
rally by  1,  active  contraction  of  vessel ;  2,  passive  contraction,  consequent 
on  decrease  of  total  quantity  of  blood  in  system  ;  3,  weakening  of  heart 
caused  by  loss  of  blood  ;  4,  obstruction  of  vessel  by  clot.  The  first  three  are, 
one  or  other,  moi-e  or  less  accessory  to  the  operation  of  the  fourth  cause. 
Venous  hemorrhage  is  stopped  partly  by  causes  similar  to  those  which 
check  arterial  hemorrhage,  and  partly  by  the  action  of  the  valves  in  the 
veins.  Capillary  hemorrhage  is  stopped  by  the  contraction  of  the  connective 
or  other  tissues  in  which  the  vessels  are  embedded,  and  by  coagulation. 
Hence,  when  these  tissues  are  diseased,  capillaiy  and  also  parenchymatous 
hemorrhage  may  be  very  troublesome.  Pathology. — Natural  changes  in  and 
around  a  wounded  vessel,  a.  If  wound  be  partial  and  transverse,  the  wound 
gapes  ;  bleeding  is  considerable  and  has  to  be  checked  ultimately  b}^  clotting, 
which  may  not  occur  till  syncope  comes  on  and  predisposes  to  it.  b.  Wotmd 
longitudinal.  Wound  does  not  tend  to  gape.  Hemorrhage  is,  therefore, 
more  easily  checked  by  coagulation  and  contraction,  c.  Wound  completely 
dividing  artery.  1.  The  ends  of  the  artery  retract  into  the  sheath,  sometimes 
curling  or  twisting  up  ;  2,  the  ends  contract ;  3,  coagulation  takes  place 
within  the  artery ;  4,  coagulation  occurs  outside  the  artery,  within  and 


110  HEMORRHAGE. 

sometimes  without  the  sheath ;  5,  organization  of  the  clot  or  of  part  of  it 
finally,  cicatricial  contraction  occurs  in  the  newly  organized  tissue.  Eecur- 
rent  hemorrhages  are  caused  by  the  retui-ning  force  of  the  circulation, 
which,  when  a  patient  becomes  warm  in  bed,  may  be  enough  to  open  a 
vessel  not  firmly  closed. 

General  Symptoms  of  Hemorrhage. — 1,  Face  first  pale,  then  blue  ;  2, 
pulse  sinks  ;  3,  temperature  sinks  ;  4,  dizziness  ;  5,  nausea  or  vomiting  ; 
6,  eyes  dazzled  ;  7,  noises  in  ears  ;  8,  fainting  and  unconsciousness  ;  9, 
either  the  patient  recovers  or  gets  worse.  In  the  latter  event  the  following 
set  of  symptoms  are  noticed  :  1,  face  waxy  ;  2,  lips  blue  ;  3,  eyes  dull ;  4, 
body  cold  ;  5,  pulse  thready,  frequent  ;  6,  breathing  incomplete  ;  7,  re- 
peated swooniugs ;  8,  permanent  unconsciousness ;  9,  twitchings  of  arms 
and  legs  ;  then  death. 

Treatment. — Many  cases  require  great  decision,  sound  anatomical  knowl- 
edge, and  sanguine  courage  for  their  proper  treatment.  Classification  of 
local  remedies,  seven  chief  classes,  viz.  :  1,  ligature ;  2,  torsion  ;  3,  acu- 
pressure ;  4,  compression  ;  5,  flexion  ;  6,  styptics  ;  7,  position. 

Ligature. — Divided  into  1,  ligature  at  the  bleeding  point,  and  2,  liga- 
ture of  the  artery  above  the  wound,  i.e.,  ligature  "in  the  continuity." 
General  rule  :  In  case  of  a  vessel  being  wounded,  cut  down  upon  the 
wounded  point,  tie  the  vessel  immediately  above  and  below  the  wound. 
But  in  some  cases  such  an  operation  would  involve  a  deep  and  large  in- 
cision, e.g.,  in  hemoiThage  from  upper  part  of  posterior  tibial  artery  ;  and 
in  other  cases,  the  artery  is  diseased  at  the  spot  bleeding.  In  such  cases 
the  artery  is  often  tied  in  the  continuity.  Materials  used  :  silk,  hemp, 
catgut.  Operation  :  Instruments  required  are  scalpel,  forceps,  retractors, 
director,  artery,  forceps  (occasionally,  also,  aneurism  needle),  tenaculum. 
In  tying  an  artexy  at  the  spot  wounded,  a  sufficiently  fi'ee  incision  should 
be  made  (usually  by  enlarging  the  wound  which  leads  down  to  the  artery), 
and  then  each  end  of  the  bleeding  artery  should  be  seized  and  hgatured  if 
the  vessel  has  been  divided  completely.  But  if  the  vessel  has  been  only 
punctured,  two  ligatures  must  be  applied  with  the  aneurism-needle,  one 
above  and  the  other  below  the  wound.  Secure  the  ligature  with  a  reef- 
knot,  pulling  each  end  of  the  knot  tight  with  the  tips  of  the  forefingers 
pressed  against  it ;  unless  catgut  be  used,  one  end  of  the  ligature  is  left 
hanging  out  of  the  wound.  To  tie  the  artery  in  the  continuity,  see  the  di- 
rections given  under  the  head  of  Aneurism.  Pathology  ;  the  Effects  of  Liga- 
ture.— Internal  and  middle  coats,  divided,  curl  up  within  external  coat, 
which  is  merely  constricted.  Formation  of  conical  plug  of  fibrin.  Inflam- 
matory new  formation  {i.e.,  escape  of  leucocytes  from  blood-vessels  into 
and  aroimd  clot  and  arterial  coats,  and  their  organization  into  fibrous  tis- 
sue).    Tied  artery  eventually  dwindles  into  fibrous  cord. 

Torsion.— Bryant's  directions  are  :  "  The  vessel  should  be  drawn  out, 
as  in  the  application  of  the  ligatiu-e,  and  thi'ee  or  more  sharp  rotations  of 


HEMORRHAGE,  111 

the  forceps  made.  In  large  arteries,  such  as  the  femoral,  the  rotation 
should  be  repeated  till  the  sense  of  resistance  has  ceased ;  the  ends  should 
not  be  twisted  off.  In  small  arteries  the  number  of  rotations  is  of  no  im- 
portance, and  their  ends  maybe  twisted  off  or  not,  as  the  surgeon  prefers." 
"  When  the  vessels  are  atheromatous,  or  diseased,  fewer  rotations  of  the 
forceps  are  required,  the  inner  tunics  of  the  vessels  being  so  brittle  as  to 
break  up  at  once  and  incurs^e."  The  effects  of  torsion  jDractically  resemble 
those  of  the  ligatm-e,  but  the  inner  coats  curl  up  more  in  the  former  case, 
sometimes  forming  a  regular  valve.  Though  torsion  leaves  no  dead  foreign 
body  in  the  wound  like  a  piece  of  ligature,  yet  the  bruised  end  of  a  twisted 
artery  is  less  likely  to  Hve  and  form  adhesions  than  the  less  damaged  end 
of  a  ligatured  artery. 

Acupressure  has  been  noticed  separately.     See  Acupkessure. 

Compression. — Several  forms  : — 1,  Tourniquet ;  2,  digital ;  3,  ordinary 
bandages  with  or  without  graduated  compress  ;  4,  elastic  bandaging.  Chief 
kinds  of  tourniquet  are  Petit's  and  Signorini's ;  Petit's  is  most  used  for 
operations,  and  consists  of  a  webbing  band,  with  a  pad  and  a  screw  for 
tightening.  It  is  usual  to  place  a  small  compress,  made  of  a  small  soft  roll 
of  bandage  or  of  lint,  over  the  artery  to  be  compressed.  Signorini's  tour- 
niquet is  used  chiefly  in  the  treatment  of  aneurism,  and  it  consists  of  two 
curved  metal  arms,  with  a  screw-hinge  between  the  two  and  a  pad  for  the 
artery  at  the  extremity  of  one.  Lister's  tourniquet  for  the  abdominal  aorta 
is  on  the  principle  of  Signorini's.  In  applying  any  tourniquet  it  is  neces- 
sary to  adjust  it  with  great  deliberation  and  care,  otherwise  the  pad  is  very 
liable  to  slip  off  the  artery.  One  should  mention  here  the  lever  used  by 
Davy,  with  great  success,  to  compress  the  iliac  arteries,  per  rectum.  Digi- 
tal compression  is  preferable  in  almost  every  case,  1,  because  of  the  Habil- 
ity  of  all  instruments  to  slip  out  of  place  ;  2,  because  the  human  finger  is 
so  delicate,  tender,  and  elastic  when  compared  with  a  rigid  tourniquet  or 
bandage.  But  it  is  difficult  to  obtain  for  this  purpose,  and  expensive  of 
time  and  labor.  In  some  cases,  e.g.,  hemorrhage  from  internal  carotid  into 
pharynx,  no  other  form  of  compression  might  be  applicable.  Digital  is 
often  supplemented  by  the  compression  of  a  small  sand-bag,  placed  upon 
the  finger,  which  sand -bag  supplies  the  place  of  muscular  force.  Band- 
aging.— In  arterial  hemorrhage  from  a  limb,  if  an  attemjDt  be  made  to  check 
it  by  the  bandage  and  compress,  the  joints  should  be  flexed  and  the  whole 
hmb  bandaged.  There  is  a  form  of  compression  called  "  plugging  ;  "  for 
instance,  if  a  gluteal  aneurism  were  opened  freely  in  mistake  for  abscess, 
the  proximal  end  of  the  artery  would  very  likely  be  in  the  pelvis  and  inac- 
cessible ;  then  the  aneurism  would  have  to  be  stuffed  with  lint  and  the 
pelvis  bandaged,  pro  tern.,  while  further  measxires  were  considered  or  un- 
dertaken. 

Flexion.  — Is  closely  allied  to  compression,  and  should  almost  always  be 
combined  with  it.  One  objection  to  flexion  is  the  disagreeably  constrained 


112  HEMORRHAGK 

position  often  unavoidable.  To  demonstrate  the  value  of  flexion,  bend 
the  elbow  strongly  and  feel  the  pulse  at  the  wrist :  it  will  be  scarcely  per- 
ceptible. 

Styptics. — 1,  heat ;  2,  cold  ;  3,  drugs,  e.g.,  iron,  tannic  acid,  gallic  acid, 
catechu,  alum,  matico,  and  many  others.  Heat. — The  actual  cautery  is  the 
only  foi-m  in  which  the  books  speak  of  heat  as  a  styptic  ;  but,  years  ago,  be- 
fore commencing  the  study  of  medicine,  I  accidentally  observed  the  power 
which  very  warm,  that  is  decidedly  hot  water  (120°  to  140°  Fahrenheit), 
has  of  closing  small  bleeding  vessels.  In  hemorrhages  from  mucous 
membranes,  for  example,  those  which  Billroth  calls  "  parenchymatous,"  I 
believe  hot  water  to  be  much  more  effectual  than  cold  ;  so,  also,  in  oozing 
from  woviuds.  In  major  amputations  it  should  be  preferable  becauso  it  is 
less  depressing  than  cold.'  The  actual  cautery  should  be  used  at  a  black 
heat,  and  held  close  to,  but  not  touching  the  bleeding  part.  It  causes  an 
eschar  with  a  suppurating  siu'face  beneath.  Cold  is  apjDlied  chiefly  in  the 
foi*m  of  ice  or  ice-water.  The  most  powerful  styptic  drug  is  perchloride 
of  iron.  The  strongest  tinctui*e  is  usually  employed,  and  it  is  often  made 
to  saturate  a  compress.  Thus,  styptics,  pressure,  and  flexion  can  all  be 
combined  if  desirable.  Billroth  speaks  of  turpentine  as  a  most  effective 
but  painful  and  heroic  styptic.  The  above  remedies  should  be  supj)le- 
mented  by  elevation  of  the  part,  general  rest,  and  avoidance  of  anything 
likely  to  excite  the  patient's  circulation.  General  Treatment. — Is  indicated 
for  the  faintness  and  weakness  caused  by  hemorrhage.  Horizontal  pos- 
tui-e,  ammonia,  ether,  wine.  The  application  of  Esmarch's  bandage  to 
a  Hmb  has  been  suggested,  to  drive  more  blood  into  the  vital  centres 
(Wharry).  Transfusion.     See  Transfusion. 

Secondary  Hemorrhage. — Its  causes  are,  1,  defect  in  the  ligature  itself  ; 
2,  defect  in  the  manner  of  tying  it ;  3,  the  ligature's  having  been  applied 
too  near  an  offset  of  the  artery,  so  that  collateral  circulation  has  prevented 
the  formation  of  the  usual  fibrinous  plug  ;  4,  atheroma ;  5,  supj)uration 
or  sloughing  of  the  wall  of  the  artery  (which  suppuration  or  sloughing  is 
sometimes  the  result  of  a  contusion  and  sometimes  of  erysipelas)  ;  6,  vas- 
cular excitement.  The  approach  of  secondary  hemorrhage  is  usually  insid- 
ious, but  it  is  frequently  very  sudden,  and  may  be  fatal  even  in  a  few  min- 
utes if  the  artery  be  large.  Treatment  of  Secondary  Hemorrhage. — Never 
delay  or  temporize  in  these  cases.  The  first  thing  to  be  tried  is  pressure, 
and  if  properly  applied  it  will  rarely  fail.  The  mode  of  application  must 
necessarily  vary  with  the  case,  only  it  should  always  be  firm  and  uni- 
form ;  the  bandages,  unless  elastic,  should  be  starched  ;  the  compresses  over 
the  bleeding-point  should  be  carefully  graduated,  and,  if  the  bleeding 
artery  be  in  a  limb,  the  bandage  should  cover  the  whole  of  the  limb.  With 
pressure  should  be  combined  perfect  rest,  elevation,  and  flexion.     To  se- 


'  See  Practitioner,  February,  1879. 


HEMORRHOIDS.  113 

cure  rest,  splints  are  sometimes  useful.  For  vascular  excitement,  give 
vascular  sedatives,  e.g.,  tinct.  digitalis.  Vide  Treatment  of  Hemorrhage 
in  general.  When  these  means  fail,  the  choice  then  Hes  between  ligature 
of  the  bleeding  vessel  at  the  bleeding-point,  Hgature  of  the  artery  in  the 
continuity,  digital  pressure,  and  amputation  of  the  limb.  Some  cases  are 
adapted  for  the  use  of  the  actual  cautery,  of  styptics,  or  of  acuj)ressui-e. 
Ligature  of  the  artery  in  the  continuity  is  to  be  deprecated,  because  it  is 
liable  to  be  followed  by  gangrene,  and  is,  moreover,  far  from  a  certain 
remedy.  Ligature  at  the  bleeding-point  is  often  useless,  because  the  tis- 
sues are  there  so  diseased,  or  it  is  objectionable  because  it  would  involve 
opening  up  a  large  stump  nearly  healed.  Digital  pressure  is  not  always 
readily  obtainable.  Certain  cases  are  suitable  for  amputation.  These  cases 
are  secondary  hemorrhage  from  the  main  arteries  of  the  lower  extremity, 
when  pressure,  rest,  elevation,  flexion,  and  re-tying  at  the  bleeding-point 
have  failed.  In  such  cases,  tying  the  main  artery  in  the  continuity  is  very 
liable  to  be  followed  by  gangrene,  and  re-t}dng  at  the  bleeding-point  is 
often  impossible  from  the  depth  of  the  wound  and  the  state  of  the  tissues. 
Hemorrhoids. — Are  essentially  varices  of  the  inferior  hemorrhoidal 
veins.  Three  varieties,  viz.:  1,  external;  2,  internal;  3,  intero-external. 
Causes. — (a)  Predisposing :  everything  which  congests  the  portal  system 
or  the  hemorrhoidal  tributaries  of  that  system.  Constipation,  high  living, 
sedentary  habits,  liver  complaints,  indigestion,  feeble  circulation,  inflam- 
matory disease  of  the  rectum  or  other  pelvic  or  perineal  parts,  e.g.,  fistula, 
pregnancy,  relaxing  climate.  Early  manhood  and  middle  age.  Uncom- 
mon in  young  women.  (6)  Exciting  causes  :  various  forms  of  local  irrita- 
tion ;  tits  of  intemperance  in  eating  or  drinking,  dirt,  use  of  rough  irritat- 
ing material  for  the  person,  sitting  on  cold  slabs,  drastic  purgatives.  It 
wiU  be  observed  that  no  sharp  line  separates  some  of  the  exciting  fi-om 
some  of  the  predisposing  causes.  Pathology.- — All  piles  at  first  are  merely 
local  congestions  or  vascular  dilatations  ;  but  eventually  the  blood-clots  in 
some  part  of  them,  and  the  connective  tissue  and  vessels  contained  in  them 
hypertrophy.  Usually  a  small  artery  lies  in  the  centre.  External  j^iles 
vary  greatly  in  appearance,  according  as  they  are  swollen  or  contracted. 
In  the  former  case  they  are  almost  globular  and  tense  ;  in  the  latter  they 
may  be  so  shrivelled  up  as  to  look  like  mere  folds  of  thickened  skin.  In- 
ternal piles  are  classified  into  1,  longitudinal  or  fleshy,  and  2,  globular. 
The  former  are  usually  "  blind,"  that  is,  non-bleeding  ;  the  latter  are  bleed- 
ing piles.  The  former  are  sessile  and  dusky  ;  the  latter  are  more  vascular, 
and  therefore  blue  or  red,  and  often  pedunculated.  The  relative  propor- 
tion of  arterial,  venous,  and  fibrous  material  in  piles  varies  greatly.  Su- 
perficial excoriation  and  ulceration  common.  Liability  also  to  inflamma- 
tion and  strangulation.  Symptoms. — Itching,  irritation,  and  discomfort; 
then  tenesmus,  pain  in  lumbo-sacral  region  and  in  testicles  ;  in*itability  of 
bladder,  disturbed  nights,  miserable  bodily  condition,  and  pinched-up 
8 


114  HEMOERHOIDS. 

countenance.  When  there  is  hemorrhage  to  any  extent,  anaemia,  some- 
times to  the  utmost  degree,  ensues.  Hemorrhage  often  periodical :  arte- 
rial or  venous  or  capillary,  trifling  or  moderate,  or  sudden,  copious,  and 
most  injurious.  Mucous  or  muco-pui'uleut  discharge.  The  latter  indicates 
ulceration.  Complications. — Fistula,  fissure,  prolapsus,  and  the  various 
diseases  which  are  so  often  the  predisposing  causes  of  the  piles  themselves. 
Diagnosis. — From  prolapsus,  polypus,  and  condylomata.  Vide  these  dis- 
eases and  compare  s^^mptoms.  Treatment. — Remove  cause,  if  possible. 
Some  cases  obviously  require  operation  ;  others  can  plainly  be  cured  by 
gentler  means,  in  a  third  class  of  cases,  milder  treatment  should  be  tried 
fii'st,  operation  afterward,  if  necessary.  General  treatment :  gentle  exer- 
cise alternating  with  rest  on  a  cool  hard  couch  ;  temperate  diet ;  gentle 
purgatives :  conf.  senna?  co.,  sulphur,  cream  of  tartar,  Friedrichshall,  Piillna, 
Hunyadi  Janos,  etc.  Enemata  of  cold  water.  Conf.  piperis  co.  Conf. 
pip.  CO.  should  always  be  combined  with  or  followed  by  a  laxative.  Tonics 
in  suitable  cases.  Blue  pill,  taraxacum,  etc.,  for  the  liver.  Glycerine  in 
3  j.  doses.  WTien  the  piles  have  been  cured,  but  anaemia  remains,  give 
mist,  ferri  co.  or  pil.  ferri  co.  fi-eely.  Local  treatment. — I.  Non-operative. 
Cleanliness,  but  avoid  irritating  soaps ;  glycerine  soap  and  warm  water  ; 
cold  water.  If  piles  prolapse  at  stool,  return  at  once.  Astringents  :  ung. 
gallse  CO.,  astringent  injections.  Quantity  :  two  ounces  nightly.  Strength  : . 
tinct.  ferri  perchlor.  TT|,.  x.  to  aquaj  3J.  Supj^ositoria  acidi  tannici.  For 
injlamed  piles  :  foment,  poultice,  leech  the  neighborhood  of  the  pile.  When 
a  large  clot  forms  in  a  pile,  incise  pile  and  turn  out  clot.  Supj)urating 
piles  :  puncture  when  mature.  Strangulated  piles :  reduced  gently.  Re- 
lieve pain  on  general  surgical  principles.  U.  Operative  treatment.  Exter- 
nal piles  are  excised  ;  internal  are  removed  by,  1,  ligature  ;  2,  cautery  ;  3, 
nitric  acid.  Exciaion  of  External  Piles. — Seize  with  vulsellum  forceps, 
clamp,  snip  off  with  scissors  curved  on  the  flat,  pass  a  cautery  lightly  over 
stump,  unclamj)  ;  snip  off  any  pendulous  little  fold  of  skin  ;  pad  of  oiled 
lint ;  T-bandage.  Ligature  of  Internal  Piles. — Let  the  nurse  empty  patient's 
rectum  with  an  enema  shortly  before  ojDeration.  Patient  should  sit  over 
warm  water  to  relax  the  parts,  and  make  it  easier  to  protrude  the  piles. 
He  then  lies  on  one  side,  and  draws  up  his  knees.  Seize  each  tumor  with 
pile-forceps,  cut  through  that  side  of  it  next  skin  with  scissors,  surround 
base  of  tumor  with  a  hempen  thread,  tie  the  pile  very  tightly.  Cut  ends 
of  ligature  short,  oil  well,  and  push  back  the  ligatured  mass  within  the 
anus  again.  Ligature  separates  in  about  a  week.  An  anodyne  is  to  be 
given  after  the  operation,  and  a  laxative  on  the  second  day.  Aneesthesia 
often  dispensed  with.  Dress  with  dry  cotton  wool.  Cauterization  of  Inter- 
nal Piles. — Preparation  same  as  for  ligature.  Smith's  clamp,  ivory  side 
downward,  snip  off  piles  with  scissors,  sear  bases  with  actual  or  with  gal- 
vanic cautery.  Latter  said  to  cause  least  after-pain.  Unclamp  gradually, 
and  cauterize  any  bleeding  point.     Suppository  of  morphia.     Usual  to 


HAND,    DEFORMITIES    OF.  115 

anaesthetise  during  tliis  operation.  After-treatment  same  as  for  ligature. 
Kecovery  quicker.  Danger  about  the  same,  but  in  either  case  very  Httle. 
Nitric  acid. — Suitable  for  sessile  hemorrhoids.  Apply  with  a  piece  of  wood 
through  speculum.  Concave  clamp  to  protect  healthy  mucous  membrane. 
Galvanic  cautery  appHed  lightly  answers  admirably  for  sessile  hemor- 
rhoids. 

Note. — "When  operating  for  hemorrhoids,  avoid,  as  much  as  possible, 
damaging  the  line  where  the  mucous  membrane  joins  the  skin.  "When 
there  is  a  fissui-e,  operate  on  it  first. 

Hand,  Deformities  of  (inclusive  oi  fingers). — Four  classes,  viz.:  1, 
deficiency,  2  ;  excess,  3  ;  webbed  fingers,  4 ;  contractions.  It  is  rare  to 
find  a  finger  or  any  part  of  the  hand  congenitally  deficient. 

Supernumerary  fingers  are  frequent :  one  is  the  common  number,  and 
it  Ues  usually  on  ulnar  side  of  little  finger.  Thumb  may  be  bifid,  or  there 
may  be  a  supernumerary  thumb.  A  finger  may  be  too  long  or  too  short. 
A  very  rare  deformity  is  a  double  hand  on  the  same  wrist. 

Contractions. — Four  classes  :  1,  congenital ;  2,  paralytic  ;  3,  traumatic 
or  cicatricial ;  4,  rheumatic. 

Congenital  contraction  assumes  the  form  called  "  clubbed  hand,"  which 
is  analogous  to  clubbed  foot,  but  very  rare. 

Rheumatic  contraction  bends  the  finger  upon  the  palm  and  is,  practi- 
cally, the  most  important  deformity  of  the  hand.  Causes.  Either  chronic 
rheumatic  diathesis,  or  the  habit  of  pressing  on  some  round-headed  insti'u- 
ment  like  a  chisel  or  a  walking-stick.  Signs. — One  or  more  fingers,  espe- 
cially the  little  one,  is  flexed,  a  tense  subcutaneous  fibrous  band  bridging 
across  from  it  to  the  palm.  Pathology.— Chronic  inflammatory  thickening 
and  contraction  of  fibrous  tissue  between  palmar  fascia  and  sheaths  of 
flexor  tendons. 

Treatment. — Supernumerary  fingers  should  be  amputated,  as  their 
proximal  joint  sometimes  communicates  with  one  of  the  normal  metacarpo- 
phalangeal articulations.  In  such  a  case  the  base  of  the  sujoemumerary 
finger  may  be  left.  If  the  operation  is  done  at  an  early  age,  this  stump 
will  not  grow. 

Clubbed  hand  can  only  be  treated  on  the  same  principles  as  clubbed 
foot,  but  with  not  nearly  the  same  hope  of  success. 

Treat  rheumatic  contractions  in  this  way :  Divide,  subcutaneously  if 
possible,  or  else  antisepticaUy,  the  contracted  fibrous  bands,  carefully 
avoiding  any  injtuy  to  sheaths  of  tendons.  Then  extend  fingers  on  a  splint. 
Attend  to  the  cause.     See  Adams's  little  book  on  this  subject. 

"Webbed  fingers,  unless  ingeniously  treated,  reunite  after  being  cut  apart. 
Method  1. — Pass  a  metal  ring  through  the  base  of  the  web  and  keep  it 
there  till  the  aperture  cicatrizes.  Then  complete  the  separation.  Method 
2. — Wrap  a  flap  of  skin  taken  from  the  back  of  one  finger  over  the  raw  sur- 
face of  the  other  finger,  and  another  flap  of  skin  taken  from  the  palmar 


116  HARE-LIP. 

Burface  of  the  latter  finger  over  the  raw  surface  of  the  former,  utilizing,  of 
course,  the  skin  of  the  web  itself.  Method  3  {vide  Barwell,  Medical  Press 
and  Circular,  1866,  or  Holmes's  "System,"  v.,  825). — In  this,  skin  is  taken 
from  the  buttock.  Method  4. — Gradual  strangulation  of  the  web  by  a 
clamp. 

Hanging.    See  Asphyxia. 

Hare-lip. — Causes  and  Pathology. — Congenital.  Many  degrees  of  this 
deformity.  Single  hare-lip  and  double  hare-lip.  The  fissure  is  not  central, 
but  corresponds,  in  single  hare-Hp  to  one  side,  and  in  double  hair-lip  to 
both  sides,  of  the  intermaxillary  bones.  The  intermaxillary  are  the  bones 
which  form  the  front  of  the  hard  palate  and  alveoli  carrying  upper  incisor 
teeth.  Hare-lips  vary  in  depth  from  a  mere  notch  in  the  edge  of  the 
upper  lip  to  a  total  lateral  separation  of  the  intermaxillarj'-  bones.  The 
deformity  in  hare-lip  is  homologous  to  a  fissure  which  is  normal  in  some 
fishes,  but  it  has  no  homology  with  the  cleft  in  the  lip  of  the  hare.  It 
often  coexists  with  cleft-palate.  Male  sex  predisposes.  Double  harelip 
almost  always  affects  boys,  and  is  ten  times  less  common  than  the  single 
variety.  The  intermaxillary  bones  in  double  hare-lip  often  j^i'oject  for- 
ward from  the  end  of  the  nose,  and  are  frequently  only  half-developed  in 
size.  Treatment. — Operative  only.  Best  time,  third  to  fifth  month  of  in- 
fancy. Contraindicated  during  dentition  or  ill-health.  Plastic  operations 
fail  in  syphilis  (Verneuil).  Chloroform  unnecessary,  and  difficult  to  admin- 
ister. If  desired,  anaesthetic  vapor  may  be  pumped  through  a  catlieter. 
Child  in  a  lying  or  sitting  position  on  a  table  or  on  nurse's  or  surgeon's 
lap.  Secui-e  his  limbs  by  rolling  him  up  lightly  but  firmly  in  a  towel. 
Assistant  to  check  hemorrhage  by  holding  each  side  of  the  upper  lip  be- 
tween his  finger  and  thumb.  Siu'geon  sponges  for  himself,  or  lip  may  be 
secured  in  T.  Smith's  forceps.  Begin  by  separating,  with  the  knife,  the 
two  sides  of  the  lip  from  the  jaw  subjacent,  unless  the  former  structures 
be  already  very  free.  Then  pare  the  edges  of  the  cleft.  Remove  enough, 
especially  from  the  apex  of  the  cleft  and  from  the  junction  of  the  cleft 
with  the  edge  of  the  lip.  Then  suture,  strap,  and  put  on  Hainsby's  truss. 
The  incisions  are  best  made  with  a  view  to  utilizing  the  "parings"  of  the 
fissures.  Vide  diagrams  in  text-books.  In  double  hare-lip  the  whole  mar- 
gin of  the  intermaxillary  nodule  is  pared.  When  this  nodule  projects  it 
must,  unless  it  is  rudimentary,  be  broken  at  the  base  and  bent  back  to  the 
level  of  the  lip.  If  it  is  rudimentary  it  may  be  removed  altogether,  except 
the  skin  which  covers  it  anteriorly.  This  must  be  stitched  back,  either  to 
complete  the  nasal  septum  if  that  is  deficient,  or,  otherwise,  to  fill  the  gap 
in  the  lip.  Modes  of  Suture. — 1.  The  "hare-lip"  suture  proper.  Two 
pins.  Enter  and  exit  one-fourth  inch  from  fissure,  pass  deeply,  nearly 
reaching  mucous  membrane.  Lower  one  secures  coronary  artery.  Twisted 
suture.  Interrupted  wire  suture  at  red  border  of  lip.  Sharp  ends  of  pins 
nipped  off.     Pieces  of  Hnt  placed  beneath  ends  of  pins.     Strapping,  broad 


HEAD,    INJURIES    OF    THE.  11? 

at  ends  and  narrow  in  middle,  brought  across  lip.  2.  The  common  inter- 
rupted wire  suture.  This  answers  well  for  ordinary  cases  and  is  less  likely 
to  leave  scars.  All  pins  should  be  removed  on  third  day  very  gently,  the 
lip  being  well  supported  at  the  time  and  strapped  immediately  afterward. 
Act  of  suckling,  rather  beneficial  than  otherwise,  as  it  tends  to  close  the 
fissure.  In  order  to  bend  back  the  intermaxillary  bone  when  it  projects, 
instead  of  breaking  its  base  it  is  a  better  plan  to  cut  a  V-shaped  piece  out 
of  the  septum  nasi. 

Head,  Injuries  of  the. — Important,  because  almost  all  varieties  are 
Hable  to  be  compHcated  with  cerebral  mischief.  Classification  is  primarily 
anatomical.  1,  Scalp  injuries  ;  2,  fractures  of  skull ;  3,  injuries  of  brain 
and  its  membranes  ;  4,  injuries  of  cranial  nerves. 

I.  Scalp  may  be  contused  or  wounded,  or  both.  Contusions  of  Scalp. 
— Very  common.  Extravasation  may  be  diffused  or  circumscribed.  Cir- 
cumscribed extravasation  occurs  either,  1,  above  cranial  aponem-osis ;  2, 
just  beneath  it ;  or  3,  between  epicranimn  and  bone.  A  special  kind  of 
scalp  extravasation  is  CephaUicematoma,  which  lies  mostly  just  beneath 
epicranial  aponeurosis  and  very  rarely  beneath  epicranium.  Signs. — Fluc- 
tuation, hard  and  thickened  margin,  soft  centre,  rarely  any  discoloration. 
Cephalhsematoma  occurs  in  the  newly  born,  and  is  caused  by  pressure  of 
maternal  passages  or  of  obstetric  forceps.  Its  usual  situation  is  over  the 
parietal  bone.  Fluid  Contents. — Blood  with  its  corpuscles  more  or  less 
disintegrated,  its  coloring  matter  more  or  less  diffused  and  perhaps  partly 
crystallized,  while  its  plasma  is  often  partly  coagulated.  The  coagulation 
may  entangle  the  coloring  matter  and  leave  the  fluid  contents  pale  and  yel- 
low. Diagnosis. — From  fracture.  The  hardened  margin  of  an  extravasa- 
tion can  usually  be  deeply  pitted  by  steady  and  continued  pressure.  See 
Fracture.  Treatment. — Cold  and  pressure.  Afterward  discutient  lotions 
(lotio  ammonii  chloridi,  etc.).  Only  the  most  obstinate  cases  should  be 
aspirated  or  punctured  by  a  small  knife.  After  puncture  apply  antiseptic 
dressings.  When  suppuration  occurs,  open  fx'eely  and  poultice.  Scaljy, 
Wounds  of. — Often  contused  and  lacerated.  Pr-ognosis. — ^Very  good  even 
in  the  most  severe  cases,  because  the  vessels  of  the  scalp  lie  chiefly  super- 
ficial to  the  aponeurosis.  But,  for  the  same  reason,  the  blood -supply  of 
the  cranium  is  sufficiently  interrupted  in  extensive  lacerations  to  cause 
danger  of  necrosis  with  its  consequences.  Other  dangers  in  scalp-wounds 
are  erysipelas,  and  accumulation  of  jdus,  causing  puffy  swelling.  Treatment. 
— Clean  carefuUy  and  replace  flaps  accurately.  Use  sutures,  if  necessary, 
but  do  not  pass  them  through  the  aponeurosis.  Experience  of  American 
Civil  War  was  in  favor  of  sutures  ("Medical  and  Surgical  History  War  of 
Rebellion").  Dressing  should  be  just  enough  to  support  and  protect  from 
draughts  of  cold  air,  without  heating.  Bleeding  vessels  can  sometimes  be 
conveniently  secured  between  a  needle  and  twisted  suture.  Treat  com- 
plications on  general  principles,  giving  free  exit  for  pus,  etc. 


118  HEAD,    INJURIES    OF   THE. 

H  Fractures  of  Skull. — Classified  in  three  ways  :  Firstly,  into  sim- 
ple and  compound  ;  secondly,  into  fractures  of  the  vault  and  fracture  of 
the  base  ;  thirdly,  according  to  the  physical  characters  of  the  fracture, 
into  fissTU'es,  starred,  depressed,  punctured,  elevated,  and  comminuted 
fractures.  It  should  also  be  noted,  when  possible,  what  is  the  relative 
amount  of  damage  done  to  the  inner  and  outer  tables  of  the  sktill.  Causes. 
— Blows  and  falls  on  the  head,  and,  though  very  rarely,  indirect  violence, 
viz. :  falls  on  the  feet  or  blows  on  the  lower  jaw.  The  nature  of  the  frac- 
ture naturally  depends  greatly  on  the  cause.  See  pathology  following. 
Anatomy  and  Pathology. — Position  of  fracture.  This  depends  chiefly  on 
the  point  where  the  causative  force  has  been  applied,  and  on  nature  of 
force.  Sharp  instruments  cause  depressed  fractui-es  at  the  point  of  con- 
tact. Sometimes  they  only  crack  the  outer  table,  while  they  depress  the 
inner.  Heavy,  softish  bodies,  e.g.,  a  bale  of  cotton,  are  likely  to  cause 
fractures  of  the  base.  The  skull  has  been  divided  into  three  "zones,"  and 
e^idence  given  to  show  that  a  blow  on  the  vault  of  one  zone  is  likely  to 
cause  a  fracture  of  the  base  of  the  same  zone.  The  middle  zone  consists 
of  "  the  parietals,  the  squamous,  and  the  anterior  surface  of  the  petrous 
portions  of  the  temporal,  with  the  greater  part  of  the  basisphenoid."  The 
posterior  and  anterior  zones  include  the  rest  of  the  skull.  The  middle 
zone  is  the  commonest  seat  of  fracture.  Shape  of  fractures  {vide  classi- 
fication). A  very  common  shape  is  a  depression  with  three  triangular 
sides  sloping  downward  till  their  apices  meet  in  the  centre  of  the  depres- 
sion. In  fx'actures  of  the  base,  sutures — e.g.,  the  petroso-occipital— are 
sometimes  torn  open.  Most  fractures  of  the  base  are  continuations  of 
fissures  of  some  part  of  the  vault.  But  a  few  appear  to  be  genuine  cases 
of  contre-coup.  This  is  what  is  meant  by  contre-coup :  Suppose  a  watch 
lying  with  its  face  toward  the  table,  and  a  weight  to  fall  upon  the  back  of 
the  watch.  If  the  glass  cracked,  that  would  be  a  fracture  by  corUre-covp. 
In  some  of  these  cases,  the  base  of  the  skull  is  said  to  be  broken  by  con- 
cussion with  the  atlas.  One  table  is  usually  more  damaged  than  the 
other,  and  the  least  damaged  lies  toward  the  surface  where  the  violence 
has  been  applied,  therefore  the  most  damaged  is  almost  always  the  inner 
table.  Extravasations  within  the  cranium,  damage  to  internal  and  middle 
ears,  and  to  cerebral  centres  and  nerves,  as  well  as  membranes  of  brain, 
very  common.  Signs  and  Diagnosis. — Obvious  in  compound  fractures 
with  depression.  In  compound  fractures  without  depression  fissure  looks 
like  a  red  line.  One  of  the  sutures  must  not  be  mistaken  for  a  fissure. 
Simple  fractures  without  depression  can  only  be  recognized  or  suspected 
indirectly  through  their  complications.  Simple  fractures  with  depression 
have  to  be  distinguished  from  contusions  with  thick,  hard  margins.  The 
depression  in  fracture  is  generally  more  abrupt  at  one  part  of  its  margin 
than  another,  while  the  hard  margin  of  a  contusion  is  usually  tolerably 
circular  and  uniform,  as  well  as  impressionable  by  steady  pressure  with 


HEAD,    INJURIES    OF    THE.  119 

the  finger.  Fractures  of  frontal  sinuses,  or  of  mastoid  cells,  often  cause 
emphysema.  Signs  of  Fracture  of  the  Base  of  the  Skull. — Bleeding  fi-om  ear, 
nose,  or  mouth,  escape  of  cerebro-spinal  fluid  from  the  ear,'  sub-conjuncti- 
val  ecchymosis,  paralysis  of  cranial  nerves,  especially  of  the  seventh  pair. 
Tenderness  of  mastoid  process  and  ecchymosis  in  sub-occipital  region  in- 
dicate fracture  of  posterior  fossa,  unless  dii-ect  violence  has  been  applied 
to  the  tender  and  bruised  parts.  The  anatomical  explanation  of  the  above 
symptoms  is  obvious.  Hemorrhage  from  the  ear  is  the  commonest  of  them. 
A  somevs^hat  rare  symptom  of  fractured  skull  is  escape  of  brain-matter. 
Cerebro-spinal  fluid  is  very  watery,  saline,  and  contains  only  a  trace  of 
albumen,  and  the  faintest  trace  of  sugar.  When  such  a  fluid  escapes  fi'om 
the  ear  directly  after  an  injury,  it  is  pathognomonic  of  fracture  of  the  base. 
Amount  of  fluid  sometimes  very  considerable.'  In  diagnosing  fracture  of 
the  skull,  always  consider  the  brain-symptoms,  if  such  are  present,  and 
consider  also  the  nature  of  the  force  which  caused  the  accident.  Serious 
and  long-continued  cerebral  symptoms  following  a  heavy  blow  on  the 
head  are  usually  caused  by  fracture  and  its  complications.  Prognosis. — 
Depends  usually  altogether  upon  the  amount  of  injury  done  to  the  brain. 
In  estimating  this,  consider  the  cause,  the  situation,  and  the  shape  of  the 
fracture,  the  age,  habits,  and  health  of  the  patient.  The  injury  done  by 
sharp  instruments  is  generally  local  and  pretty  manifest  to  the  surgeon's 
senses.  Heav^',  blunt,  soft  bodies  are  apt  to  severely  concuss  and  contuse 
the  brain  and  fracture  the  base  of  the  skull,  while  causing  very  little  su- 
perficial damage.  Fractures  of  the  base  are  usually,  but  not  always,  fatal. 
Fractures  with  escape  of  brain- matter  have  been  recovered  from.  Frac- 
ture at  root  of  nose  may  only  afi'ect  anterior  wall  of  frontal  sinus.  Young 
children  have  no  frontal  sinus.  Depressed,  and  especially  punctured  frac- 
tures very  liable  to  wound  dura  mater  and  brain.  Kidney  disease  makes 
wounds  in  this,  as  in  other  regions,  very  serious.  Treatment. — In  all  cases, 
rest,  coolness,  low  diet,  high,  hard  pillows  beneath  head.  Ice  locally,  a 
purgative  at  commencement.  Vigorous  antiphlogistic  treatment  the  mo- 
ment signs  of  ivfiammation  appear.  Leeches.  Cold  douche.  Continue 
observation  of  simple  cases  at  least  a  month.  Eemove  loose,  depressed 
pieces  in  comminuted  fracture.  Indications  for  Trephining. — They  are 
simply  the  occurrence  and  persistence,  in  spite  of  treatment,  of  symptoms 
of  local  intracranial  suppuration,  or  hemorrhage,  or  of  cerebral  irritation, 
after  a  blow  on  the  skull.     Trephining  is  contraindicated  in  cases  of  dif- 

'  In  rare  cases,  cerebro-spinal  fluid  has  been  known  to  flow  from  nose  or  from  a 
fracture  of  the  vertex. 

-E.  W.  Collins  (Dublin  Medical  Journal,  February,  1877)  demonstrates  that  1, 
sugar  is  not  constant  in  the  fluid ;  2,  when  present,  though  reacting  to  Trommer's, 
Moore's,  and  Bottgens  tests,  it  usually  does  not  deflect  polarized  light,  or  ferment 
with  yeast ;  3,  three  constant  characters  of  cerebro-spinal  fluid  are  1,  very  low  specific 
gravity,  2,  almost  complete  absence  of  albumen,  3,  comparatively  large  proportion  of 
sodium  chloride. 


120  HEAD,    INJURIES    OF    THE. 

fused  injury  to  the  brain,  and  even  in  cases  of  depressed  fracture  unat- 
tended by  cerebral  symptoms  {vide  Gam  gee,  in  British  Medical  Journal, 
1877).  Bryant  is  "almost  tempted  to  believe  that  depressed  bone  by 
itseK  never  gives  rise  to  marked  symptoms  of  compression,  and  that  when 
these  are  present  hemorrhage  exists  with  it."  When  there  is  a  depressed 
fracture,  it  is  right  to  trephine  as  soon  as  ever  cerebral  symptoms  appear. 
Otherwise,  ice-bags,  leeches,  etc.,  should  have  a  fair  trial  first.  When 
there  is  comminution,  depressed  pieces  can  sometimes  be  raised  by  the 
elevator  or  forceps  only.  See  article  Trephining.  Further  points  are 
touched  upon  in  the  next  section,  which  is  about — 

ni.  Injukies  of  the  Brain  and  its  MEiisRANEs.  — These  include  extravasa- 
tions of  blood  within  the  cranium,  contusion  and  laceration,  inflammation 
and  suppui-ation  of  traumatic  origin,  hernia  cerebri ;  and  here  also  must 
be  noticed  the  conditions  styled  "  concussion"  and  "compression." 

Extravasations  of  Blood  within  the  Cranium. — 1,  Between  dura  mater 
and  bone  ;  2,  in  carity  of  arachnoid ;  3,  on  the  surface  of  the  brain  be- 
tween it  and  the  arachnoid ;  4,  in  the  substance  of  the  brain  or  in  its 
ventricles.  1.  Extravasation  between  dura  mater  and  bone.  Causes. — 
Wounded  blood-vessel,  usually  a  branch  of  middle  meningeal  artery,  some- 
times a  wounded  sinus,  especially  the  lateral  sinus.  Pathology. — The 
efifused  blood  forms  a  clot,  often  of  enormous  size  and  having  very  little 
tendency  either  to  be  absorbed  or  to  become  encysted.  Tliis  clot,  when 
large,  causes  a  corresponding  depression  on  the  surface  of  the  bi'ain. 
Signs. — May  be  nil  if  clot  be  small,  or  even  in  the  case  of  a  large  hemor- 
rhage, if  it  be  poured  out  so  gradually  that  "  the  brain  has  time  to  accom- 
modate itself  to  the  pressure."  When  symptoms  are  present  they  are  those 
of  compression  or  of  irritation.  The  most  valuable  evidence  of  extravasa- 
tion exists  when  symptoms  of  compression  come  on,  not  immediately  after 
an  injury,  but  after  an  interval  of  consciousness.  For  prognosis,  treat- 
ment, etc.,  see  paragraphs  about  Compression.  It  is  to  be  noted  that 
irritation  of  the  nerves  of  the  dura  mater  causes  reflex  convulsions  and 
contractures  of  the  same  side  of  the  body  as  the  injury  to  the  head.  2. 
Extravasation  in  cavity  of  arachnoid.  Veiy  common.  Pathology. — When 
not  absorbed,  has  a  tendency  to  form  blood-cysts  contained  in  a  new  fibro- 
serous  membrane  which  is  attached  to  the  parietal  layer  of  the  arachnoid, 
and  makes  a  depression  on  the  surface  of  the  brain.  Signs  and  Diagnosis. 
— Cannot  be  distinguished  from  other  intra-cranial  hemorrhages.  Long 
after  the  original  injiiry,  it  is  hable  to  cause  headaches  and  mental  irrita- 
bility. Treatment,  etc.,  see  Compression  and  Cerebral  Irritation.  3.  Extra- 
vasation on  surface  of  brain,  beneath  visceral  arachnoid.  Accompanies 
general  cerebral  injuries.  Never  encysted.  May  spread  very  widely.  No 
special  signs.  No  special  treatment.  4.  Extravasations  into  substance  of 
brain  or  into  its  ventricles.  Not  to  be  distinguished  from  apoplexy  except 
by  the  history.     Treatment,  etc.,  as  in  Apoplexy. 


HEAD,    INJURIES    OF   THE.  121 

Contusion  and  Laceration  of  Brain. — Pathological  Anatomy. — Minute 
extravasations,  sometimes  lew,  sometimes  numerous,  sometimes  occupying 
only  a  limited  portion  of  gray  matter,  sometimes  diffused  through  greater 
part  of  brain  ;  sometimes  attended  with  very  httle  injury  to  cerebral  sub- 
stance, sometimes  followed  by  comj)lete  softening  and  disintegration,  or, 
after  a  longer  interval  of  time,  by  atrophy  of  brain-substance.  Situation 
often  opposite  the  part  of  cranium  struck  (contre-coup) .  Usually  middle  or 
anterior  fossa  of  base.  Lacerations  are  often  complicated  with  large  extra- 
vasations. Symptoms. — Partial  spasms  and  paralysis,  occasionally  coma. 
Frequently  concussion.  None  of  these  sy mj)toms  belong  specially  to  cerebral 
contusion  and  laceration,  which  are  so  difficult  to  diagnose  satisfactorily 
that  their  treatment,  etc.,  will  best  be  considered  under  the  heads  of  con- 
cussion, compression,  cerebral  inflammation,  iiTitation,  etc. 

Encephalitis,  Traumatic. — This  includes  meningitis,  for,  during  life,  in- 
flammation of  the  membranes  cannot  be  diagnosed  from  that  of  the  brain- 
substance  ;  though  a  shrewd  guess  may  sometimes  be  formed  by  consider- 
ing the  exciting  cause.  Classified  into  :  1,  acute,  and  2,  subacute  or 
chronic.  Causes. — All  injuries  of  the  head.  For  even  a  scalp  wound  may 
excite  firstly,  osteitis,  and  secondarily,  meningitis  and  cerebritis.  Neglect 
of  rest  and  of  temperance  after  head  injuries  is  very  likely  to  excite  inflam- 
mation. Pathology. — Congestion  of  the  parts  inflamed.  Firstly,  yellowish 
lymph  and  then  pus  appears  on  the  inflamed  membranes.  Cerebral  sub- 
stance may  soften  and  break  down.  Serous  effusion  into  ventricles.  WTien 
the  exciting  injury  is  not  very  deep,  e.g.,  most  punctured  fractui-es,  the 
membranes  are  chiefly  affected  ;  but  when  it  is  general  or  deep,  e.g.,  con- 
tusion of  brain,  the  cerebral  substance  may  be  the  chief  seat  of  inflam- 
mation. Although  the  ai3pearances  are  most  marked  at  the  actual  seat  of 
injury,  yet  traumatic  encephalitis  generally  spreads  to  a  great  part  of  the 
brain  and  its  membranes.  In  chronic  cases,  parietal  and  visceral  layers  of 
arachnoid  cohere.  The  amount  of  cerebral  congestion  is  estimated  j^ost 
mortem  by  the  number  and  size  of  the  red  points  visible  on  section  of 
the  hemispheres.  This  test  is  not  satisfactory,  for  it  is  influenced  by  the 
relative  fluidity  of  the  blood  and  the  pressm-e  of  serous  effusion  in  the 
ventricles.  Signs. — 1,  Acute.  Severe  pain  in  head,  over-sensitiveness  to 
light  and  sound,  noises  in  ears,  one  or  both  pupils  contracted,  partial 
spasms  and  paralyses,  ej^ileptiform  convulsions,  usually,  or  at  all  events  at 
first,  unilateral ;  fever,  pulse  frequent,  or  variable,  temperature  raised 
sHghtly  at  first,  and  raised  more  if  suppuration  come  on.  Vomiting. 
Dehrium.  Lastly,  coma,  and  death  by  exhaustion  and  compression.  The 
relative  prominence  of  the  symptoms  catalogued  above  varies  greatly  in 
different  cases.  In  comatose  stage  pupils  eventually  dilate.  2.  Chronic. — 
When  it  comes  on  long  after  receipt  of  injury,  there  may  be  i^remonitory 
signs,  e.g.,  irritable  temper,  headaches,  etc.  The  symptoms  differ  only 
from  those  of  acute  inflammation  in  beiner  less  concentrated  and  severe. 


122  HEAD,    INJURIES    OF   THE. 

Diagnosis. — Traumatic  intra-cranial  inflammation  can  scarcely  be  con- 
founded with  any  other  disease  if  its  causes  and  signs  are  carefully  con- 
sidered. Frognosis. — Very  serious,  especially  if  not  treated  promptly  and 
boldly.  Treatment. — Cold  locally,  pui'ging,  calomel,  venesection,  leeclauo-, 
morphia.  Venesection  rarely  used  now.  Leeching  over  temples  and 
mastoid  processes  very  beneficial.  But  local  cold  is  the  most  powerful 
remedy.  The  cold  douche  is  the  most  effective  form,  and  it  should  be  used 
courageously  and  perseveringly.  Ice-bags.  Purging  is  highly  praised. 
Calomel  and  butter  placed  on  tongue.  Small  doses  of  calomel  and  morphia 
sometimes  given,  especially  when  furious  delirium  comes  on  a  few  days 
after  a  head-injury.  Dark  room,  head  raised  on  high  hard  pillows,  hair 
cut  short.  For  treatment  when  suppiu-ation  supervenes  see  following 
paragraph.  Probably  many  cerebral  inflammations  which  have  resulted 
from  wounds  would  have  been  jorevented  by  antiseptic  dressings. 

Intracranial  Suppuration. — Within  the  skull,  as  elsewhere,  suppuration 
is  one  of  the  "  terminations  "  of  inflammation  ;  it  is  practically  very  impox'- 
tant  whether  the  pus  be  between  the  skull  and  dura  mater,  just  beneath 
the  dura  mater,  or  within  the  brain  substance.  Signs. — Not  decisive. 
S^'mptoms  of  compression  gradually  coming  on  during  encephalitis  and 
accompanied  by  further  rise  of  temperature,  and  rigors.  At  the  same  time 
a  coexistent  scalp  wound  may  become  pale  and  dry,  or  Pott's  puffy  swell- 
ing may  form.  If  the  wound  be  deep  enough,  the  bone  may  perhaps  be 
seen  exposed  by  separation  of  pericranium.  When  these  local  signs  are 
present,  it  is  not  unlikely  that  the  pus  is  lying  just  beneath  that  part  of  the 
skull.  Prognosis  very  bad  ;  to  make  it  worse,  pysemia  is  a  not  unfrequent 
comi:»lication.  Treatment. — The  main  question  is  that  of  trephining.  Dif- 
ficulty of  treatment  consequent  on  difficulty  of  diagnosis.  When  above 
symptoms  are  well-marked,  trephining  is  clearly  indicated.  Then,  if 
brain  is  not  found  pulsating  beneath  exposed  dura  mater,  that  membrane 
may  be  punctured.  The  knife  has  been  plunged  bodily  into  the  brain  it- 
self, not  without  success.     Operate  antiseptically. 

Hernia  Cerebri. — Causes. — Wound  of  skull  and  dura  mater,  followed 
by  inflammation  of  part  of  brain  immediately  beneath  it.  More  common 
in  children,  and  when  aperture  in  skull  is  small  than  when  it  is  large. 
Pathologrj. — Inflammatoiy  proHferation  of  connective  tissue  of  brain,  lead- 
ing to  a  hernia  of  a  substance  whose  structure  is  sometimes  entirely  like 
that  of  granulation-tissue,  brain- substance,  and  clotted  blood,  and  some- 
times of  blood-clot  only.  Signs. — Hernia  usually  appears  a  few  days  after 
injury,  but  may  appear  much  later.  Brown,  or  reddish-brown  mass,  pul- 
sating synchronously  with  respiration,  and  increasing  in  size.  Brain  symp- 
toms, sometimes  very  slight  at  first,  are  those  of  cerebral  irritation  and  in- 
flammation. In  fatal  cases,  death  ensues  fi-om  the  encephalitis,  Frognosis 
bad.  Diagnosis. — From  fimgus  of  dura  mater  and  fungus  of  cranium. 
Former  appears  gradually,  and  is  preceded  by  no  fracture  from  external 


HEAD,    INJURIES    OF   THE. 


123 


violence,  latter  does  not  pulsate.  Treatment. — Protective  and  slightly 
compressive.  Shaving  off  is  contraindicated.  A  hollow  metal  cap  fitting 
accurately.  Any  ordinary  dressing,  combined  with  compression  by  a  soft 
pad  and  bandage. 

Compression  AND  Concussion  OF  Brain. — "Compression"  and  "Concus- 
sion," two  terms  which  represent  each  a  peculiar  and  important  assemblage 
of  symptoms,  rather  than  a  definite  pathological  state.  Persons  suffering 
from  concussion  are,  in  common  parlance,  said  to  be  stunned.  Compres- 
sion means  a  more  alarming  condition,  in  which  the  patient  cannot  be 
aroused  from  stupor,  and  lies  wholly  or  partially  paralyzed.  The  presence 
or  absence  of  paralysis  has  been  given  as  the  distinguishing  mark  between 
the  two  states.  Still  there  are  cases  which  partake  so  of  the  nature  of  both, 
that  no  one  would  class  them  under  either  head,  except  persons  endowed 
with  exceptional  decision  of  character  and  indifference  to  both  detail  and 
accuracy.  The  origin  of  the  terms  sliould  always  be  borne  in  mind  : 
"  concussion,"  of  course,  means  "  shaking  "  or  "  striking,"  and  "  compres- 
sion "  implies  the  pressure  of  something,  e.g.,  blood,  or  pus,  or  bone,  or 
serum,  on  the  brain. 

Compression. — Pathology. — Depressed  fracture  of  skull,  extravasated 
blood  within  the  cranium,  inflammatory  thickening  or  oedema  of  the  brain, 
or  pus  within  the  cranium  are  found,  besides  in  each  case  various  condi- 
tions such  as  are  sketched  in  the  above  notices  of  contusion,  intracranial 
hemorrhage,  inflammation,  etc.  Symptoms  of  Compression  and  Concus- 
sion contrasted  : 


Compression. 

1.  Total  insensibility. 

2.  Respiration  stertorous,  slow,  and  puff- 

inp:. 

3.  Pulse  full,  slow,  labored. 

4.  Special  senses  paralyzed. 

5.  Pupils  widely  dilated,    or,   sometimes 

one  dilated  and  the  other  normal  or 
contracted. 

6.  Stomach  insensitive. 

7.  Sphincters     may     be    paralyzed,    but 

bowels  are  torpid. 

8.  Bladder  paralyzed.     Consequent  reten- 

tion of  urine. 

9.  Does  not  usually  appear  at  moment  of 

injury,  but  afterward,  and  tends  to 
get  worse. 


Concussion. 

1.  Insensibility,  from  which    patient  can 

usually  be  partly  aroused. 

2.  Respiration  feeble,  like  that  of  a  person 

in  a  faint  condition. 

3.  Pulse  weak,  irregular,  and    often  fre- 

quent. 

4.  Special  senses  dulled. 

5.  Pupils  variable  but  usually  sensitive  to 

light. 

6.  Nausea  as  recovery  is  taking  place. 

7.  Bowels  relaxed,  but  sphincters  not  parar 

lyzed. 

8.  Bladder  can  expel  water. 

9.  Comes  on  instantaneously  and  passes  off 

gradually. 


Concussion. — Pathology. — No  thoroughly  satisfactory  evidence  of  con- 
cussion's occurring  without  some  bruising  or  laceration  of  the   brain. 


124  HEAD,    INJURIES    OE    THE. 

Symptoms. — See  table  contrasting  them  with  those  of  compression.  Ter- 
minations.— Recovery  may  be,  and  usually  is,  perfect ;  or  there  remain 
headaches,  mental  irritability,  affections  of  the  senses,  weakness,  impaired 
virility,  epilepsy.  Concussion'  frequently  passes  into  compression.  See 
Contusion  and  Laceration  of  Brain  (p.  121).  Treatment. — At  first,  warmth, 
hot  blankets,  hot  bottles,  friction,  and  other  gentle  remedies  for  shock. 
Alcohol  contraindicated.  And  it  should  always  be  bome  in  mind  that  con- 
cussion is  not  usually  in  itself  dangerous,  but  that  it  is  quite  possible  by 
too  vigorous  and  too  stimulating  a  treatment  to  bring  on  hemoiThage  or 
inflammation.  When  reaction  has  taken  place,  if  not  before,  precaution- 
ary measures  against  hemorrhage,  inflammation,  etc.,  should  at  once  be 
adopted.     See  Precautionary  Treatment  of  Fractures  of  Skull. 

Treatment  of  Compression  varies  with  the  suspected  or  known  cause, 
whether  extravasated  blood,  or  depressed  fracture,  or  inflammation,  or 
suppuration,  or  foreign  body.  But  always  attend  to  these  points — 1,  dark 
room  ;  2,  head  l\igh  ;  3,  head  shaved  ;  4,  head  cool ;  5,  low  diet ;  6,  see 
that  the  bowels  act  freely,  if  necessary,  placing  a  drop  of  croton  oil  in  a 
little  sugar  on  the  tongue.  The  treatments  of  inflammation  and  suppura- 
tion are  given  above.  The  question  of  trephining  for  compression  has 
been  answered  in  the  affirmative  or  the  negative,  according  as  the  intra- 
cranial mischief  is  believed  to  be  local  and  accessible  or  to  be  general. 
But  I  am  inclined  to  hold  that  the  introduction  of  the  antiseptic  treatment 
reopens  this  question,  and  that  antiseptic  ti-ephining  may  be  justifiable  to 
relieve  general  intracranial  tension.'  I  must  again  also  call  attention  to 
the  power  of  the  cold  douche  long  continued,  e.g.,  for  hours,  over  intra- 
cranial iiiflammations. 

Cerebral  Irritation. — Pathology. — Probably  laceration  of  brain.  Symp- 
toms.''— Graphically  described  in  Erichsen — 1,  bodily  ;  2,  mental.  Bodily : 
attitude  of  general  flexion — knees  drawn  up,  elbows  bent,  etc.  ;  restless- 
ness ;  eyelids  firmly  closed  ;  no  heat  of  head  ;  pulse  weak  and  not  fre- 
quent ;  rarely  retention.  Mental  :  irritable  temper,  desire  to  be  let  alone  ; 
muttering,  frowning,  grinding  of  teeth  if  disturbed.  When  these  symp- 
toms subside,  the  mind  is  left  for  a  long  time  weak  and  fatuous.  Treat- 
vient. — On  general  principles  ;  rest,  darkness,  quiet,  coolness,  ice-bag, 
patience.  Chloral  and  even  morphia  may  be  given  in  some  cases  ;  but 
theii-  effects  should  be  keenly  and  cautiously  watched. 

IV.  Injuries  of  Cranial  Nerves.— Causes.— Fractures  of  bones  of  skull, 
extravasated  blood,  inflammatory  effusion.  Signs. — May  be  deduced  from 
consideration  of  functions  of  these  nerves.  Paralysis  in  most  cases,  spasms 
in  some.     Disturbed  nutrition  of  cornea  and  conjunctiva  when  fifth  nerve 


'  See  Yeo,    British  Medical  Journal,  May  14,  1881. 

'  Not  unlikely  that  the  peculiarity  of  this  set  of  symptoms  is  due  rather  to  the  part 
injured  than  to  the  kind  of  injury. 


HERNIA.  125 

is  injured.  Prognosis. — Usually  unfavorable ;  but  wben  tlie  paralysis  or 
spasms  come  on  during  attacks  of  intracranial  inflammation,  recovery  may 
take  place  on  absoi*ption  of  inflammatory  effusion.  Treatment. — If  possible 
remove  the  cause.  Nerves  most  frequently  affected  are  seventh  and  second 
pairs.  To  complete  these  notes  on  injm-ies  of  the  head,  we  must  notice 
traumatic  osteitis  of  the  cranial  bones,  which  when  acute  is  usually  called 
"  inflammation  of  the  diploe."  Chronic  osteitis  of  cranium  follows  any  in- 
jury (of  course  it  is  sometimes  syphilitic)  ;  it  may  result  in  hypertrophy, 
caries,  or  necrosis.  Acute  inflammation  of  cranium  is  very  dangerous  from 
its  liability  to  spread  to  membranes  of  brain. 

Heart,  Injuries  of.     See  Injuries  of  Chest. 

Hernia. — This  word,  which  probably  is  derived  from  Greek  ernos,  a 
shoot,  is  applied  to  the  projection  of  a  viscus  through  the  wall  of  any  of 
the  body-cavities,  e.g.,  hernia  cerebri,  hernia  of  lung  ;  and,  by  extension, 
it  is  given  even  to  such  phenomena  as  bulging  of  tunica  intima  of  an  artery 
through  an  opening  in  the  media  and  adventitia.  But  "  hernia "  used 
without  qualification  refers  only  to  hernia  abdominalis.  Causes. — Predis- 
posing :  1.  Sex,  four  times  as  often  in  males  as  in  females.  2.  Age,  most 
hernias  develop  before  age  of  35.  3,  Occupation,  habit  of  making  violent 
efforts.  4.  Hereditary  conformation,  including  patent  tunica  vaguialis 
funiculi,  abnormal  laxity  of  mesentery,  congenital  defects  of  abdominal 
walls.  5.  General  weakness  of  the  system.  6.  Excessive  obesity  and  flab- 
biness.  7.  Pregnancy.  8.  Defects  in  abdominal  wall  of  traumatic  origin, 
cicatrices,  etc.  Observe  that  number  4  includes  three  causes.  Cause  6 
acts  strongly  if  obesity  rapidly  diminishes.  Exciling  Causes. — Sometimes 
a  strain,  or  violent  efforts  often  repeated.  Cough.  In  male  infants,  the 
application  of  a  truss  to  an  umbilical  hernia  may  result  in  the  production 
of  an  inguinal  hernia.  Symptoms. — In  earliest  stage,  merely  "weakness  " 
locally,  with  slight  fulness  in  erect  position  and  impulse  on  coughing. 
Then  a  soft,  round  or  oblong  tumor  develops,  reducible  generally  with  a 
gurgling  noise.  If  containing  omentum  it  is  called  "  epiplocele,"  and  may 
be  hard  and  lobulated.  Herniae  are  opaque,  and  dull  on  gentle  percus- 
sion. Mode  of  appearance  and  growth,  usually  sudden  in  "  congenital " 
hernia,  gradual  in  other  forms.  A  hernia  passes  by  a  broad  neck  into  the 
abdomen.  Subjective  signs  are  dragging  pains  and  dyspeptic  feelings. 
Hernia^  are  often  irreducible.  Anatomy. — A  hernia  consists  of  (1)  con- 
tents, (2)  sac,  (3)  coverings.  Contents :  intestine,  omentum,  or,  more 
rarely,  one  of  the  other  abdominal  or  pelvic  viscera,  e.g.,  ovary,  stomach, 
gall-bladder.  Fluid  between  sac  and  contents,  variable  in  quantity.  An 
"  enterocele  "  contains  bowel  only,  an  "  epiplocele  "  omentum  only,  an 
"  entero-epiplocele  "  both.  Sac  is  continuous  with  peritoneum.  It  is 
identical  with  tunica  vaginalis  in  "  congenital "  hernia  ;  but,  in  other  cases, 
is  fonned  by  gradual  pushing  out  of  a  pouch  of  peritoneum.  It  consists 
of  a  mouth,  neck,  body,  and  fundus.     Mouth  and  neck  are  originally  puck- 


126  HERNIA. 

ered ;  but,  witli  time,  this  puckering  obliterates,  and,  still  later,  tbe  neck 
and  mouth  are  apt  to  thicken  and  contract.  Hence  many  cases  of  stran- 
gulation. If  a  hernia  be  reduced  before  its  sac  has  had  time  to  grow  old, 
thickened,  and  adherent,  the  sac  will  be  drawn  up  into  the  general  peri- 
toneal lining  of  the  abdomen  again.  Diagnosis. — See  special  varieties  of 
hernia,  especially  inguinal  and  femoral.  Prognosis. — In  spite  of  the  regu- 
lar use  of  trusses,  hernia  usually  persists  throughout  life.  Fau'  prospect 
of  recovery  in  umbilical  hernia  of  male  infants,  and  in  slight  inguinal  her- 
nise  promptly,  patiently,  and  persistently  ti-eated.  Congenital  hernise  are 
most  liable  to  strangulation,  iiTeducible  hemiie  to  obstruction.  Umbilical 
hernial  of  women  may  attain  enormous  si^e,  especially  in  fat,  flabby  women. 
So  also  may  other  hemise,  if  neglected.  Treatment. — Palliative,  that  is  the 
truss.  Common  truss,  single  or  double,  inguinal  or  femoral ;  Salmon  & 
Ody's  ;  mocmain  ;  various  pads.  Wood's  horse  shoe  pad,  circular  pyriform 
and  oval  pads,  water-pads/  air-pads.  Bag-trusses  for  irreducible  hernia. 
Spring  of  common  truss  encircles  pelvis  just  below  crest  and  anterior  su- 
perior spines  of  ilium.  Salmon  &  Ody's  has  a  ball-and-socket  joint,  with 
a  spring  going  half  round  body  on  side  opposite  to  rupture.  Mocmain  has 
a  soft  belt  with  a  lever  spring  near  the  pad.  Wood  dii-ects  pad  to  be  flat, 
saying  that  rounded  pads  tend  to  dilate  hernial  apertures.  For  umbilical 
hernia,  pads  with  belts,  corks,  strapping,  etc.     See  Umbilical  Hernia. 

Points  to  be  noted  in  fitting  a  truss  :  1,  side  of  hernia  (right  or  left)  ;  2, 
size  of  projection  ;  3,  size  of  hernial  aperture  ;  4,  kind  of  hernia  (inguinal 
or  femoral).  Measurements :  1,  girth  of  body  midway  between  gi-eat  tro- 
chanter and  anterior  superior  spine  of  iUum  ;  2,  distance  between  anterior 
superior  spine  and  hernial  aperture  ;  3,  direction  in  which  pressui-e  should 
be  made.  In  fat,  large-beUied  people  this  is  usually  upward  and  back- 
ward, in  thin  peoj)le  it  may  be  simply  backward.  The  pressure  of  the 
spring  should  be  adjusted  carefully.  Infants  should  have  two  trusses, 
that  one  may  be  worn  while  the  other  is  being  cleaned.  Mocmain  truss 
probably  most  comfortable,  but  has  very  little  strength.  Persons  who 
have  to  make  great  efforts  occasionally  should  have  an  extra  strong  truss 
for  such  times. 

Eadical  Cure  of  Hernia,  Operative  Treatment. — See  Wood  on  Eupture, 
or  some  large  treatise  on  surgery.  The  operation  is  done  only  for  irigui- 
nal  hernia. 

Complications  of  Hernia,  three  primary  ones,  viz. :  1,  obstruction ;  2, 
strangulation ;  3,  inflammation.  Gangrene  and  ulceration  are  secondary 
to  one  of  these  primary  complications. 

Obstructed  Hernia. — In  this  condition  the  impediment  to  the  transit  of 
f.fces  lies  within  the  bowel,  not  external  to  it  as  in  strangulation.  But 
the  symptoms  differ  from  those  of  strangulation  chiefly  in  degi'ee.  When 
obstruction  is  complicated  with  inflammation,  diagnosis  from  strangulation 
is  very  difl&cult.     Umbilical  hemise  are  the  favorite  seats  of  obstruction. 


HERNIA.  127 

Pain,  flatulence  of  tumor,  increased  tension  and  size  of  tumor  ;  on  ma- 
nipulation, gurgling  may  be  produced  and  solid  fecal  matter  felt.  Fever- 
ishness,  nausea,  vomiting.  Treatment. — Poultices  and  aperient  enemata. 
Gentle  purgations  before  vomiting  occui-s. 

When  an  ii-reducible  hernia  is  obstructed,  it  is  sometimes  called  an 
"incarcerated  hernia." 

Strangulated  Hernia. — The  herniated  parts  are  so  compressed  at  or 
near  neck  of  sac  that  the  circulation  of  blood  through  their  vessels  and  of 
fecal  matter  through  herniated  intestine  is  obstructed.  Predi^podng 
Causes. — Disordered  or  relaxed  state  of  health.  Sudden  formation  and 
descent  of  a  congenital  hernia.  Working  -without  having  the  prudence 
to  keep  up  a  hernia  by  a  truss.  Symptoms. — Local :  para,  tenderness, 
swelling,  usually  increased  tension,  uneasy  feeling  in  hypogastrium, 
dragging  sensations  from  neighborhood  of  rupture.  General :  nausea, 
anorexia,  vomiting,  constipation,  tenesmus  ;  feverishness,  flushed  cheeks, 
frequent  pulse,  furred  tongue.  Then  vomiting  gets  worse,  local  tender- 
ness increases,  peritonitis  comes  on,  patient  collapses  and  dies.  The 
vomiting  is  rarely  absent.  It  is  of  a  characteristic  nature.  Large  quanti- 
ties of  fluid  are  thrown  out  of  the  mouth  with  a  sudden  gush.  This  fluid 
at  first  comes  from  stomach,  then  intestines,  it  is  then  called  "fecal," 
sometimes  "stercoraceous."  Constipation  is  complete.  Pathology. — Con- 
striction of  hernial  tumor  at  point  of  strangulation,  so  that  when  the  bowel 
is  liberated  a  distinct  gi-oove  still  remains,  marking  the  line  of  stricture. 
Changes  which  take  place  in  strangulated  bowel  or  omentum  are,  1,  con- 
gestion and  sw^elling  ;  2,  inflammation  ;  3,  gangrene.  The  signs  of  these 
three  stages  will  be  given  in  describing  the  operation  of  herniotomy  ;  as 
it  is  most  important  to  bear  them  in  mind  during  that  operation.  The 
fluid  in  the  sac  will  be  described  at  the  same  time.  Diagiiosis. — Generally 
easy.  But,  if  the  general  symptoms  of  intestinal  obstruction  coexist  with 
any  tumor  in  one  of  the  recognized  seats  of  hernia,  unless  that  tumor  is 
known  positively  not  to  be  a  hernia,  and  rmless  the  case  is  yielding  to 
other  treatment,  the  sui-geon  should  cut  down  upon  the  tumor.  Very  lit- 
tle harm  can  result  from  the  procedure.  Strangulation  is  sometimes  diffi- 
cult to  distinguish  from  mere  obstruction  "with  inflammation.  In  the 
latter  case  there  is  less  vomiting,  always  great  local  tenderness,  and,  in- 
stead of  absolute  constipation,  the  occasional  passage  of  flatus  and  liquid. 
It  is  to  be  borne  in  mind  that  peritonitis  may  complicate  vdthout  being 
caused  by  a  hernia.  Treatment. — 1,  Taxis  ;  2,  warm  bath  ;  3,  opium  ;  4,  rest 
in  warm  bed  ;  5,  anaesthesia  ;  6,  herniotomy.  Although  numbers  2,  3  and 
4  are  usually  described  as  auxiliary  to  the  taxis,  I  put  them  separately  for 
two  reasons,  viz. :  1,  that  they  are  in  a  few  cases  perfectly  competent  to  re- 
duce the  hernia  without  the  assistance  of  the  taxis ;  2,  that  they  are  much 
underrated  now-a-days  in  consequence  of  the  reaction  against  that  sad 
mistake  which  has  allowed  so  many  cases  to  pass  beyond  hope  before 


128  HERNIA. 

operation,  and  in  consequence  of  the  notion  that  these  minor  remedies  act 
only  by  relaxing  the  constricting  bands  ;  whereas  they  may  act  directly  on 
the  strangulated  parts  themselves  by  reducing  the  congestion  and  conse- 
quently the  size  of  the  strangulated  intestine.  Some  amount  of  circulation 
must  usually  exist  during  the  first  stages  of  strangulation,  or  the  intestine 
would  not  live  as  long  as  it  does.  In  every  case,  firstly  make  a  short  and 
gentle  application  of  the  taxis.  Secondly,  give  20  minims  of  laudanum, 
then  a  warm  bath  for  a  time  proportional  to  patient's  strength,  and  then 
place  him  in  bed  between  blankets. 

Still  keeping  the  patient  warm  in  blankets,  angesthetise  him,  and  try 
the  taxis  gently  again.  If  it  fail  this  time,  operate  at  once.  The  taxis. 
Position  of  patient,  supine  with  his  legs  drawn  up.  Bear  in  mind  resist- 
ing forces,  viz. :  1,  tightness  of  consti'icting  ring  or  band,  2,  swelling  of 
strangulated  viscus.  Manipulate  hernia  as  nearly  as  possible  into  a  line 
with  the  axis  of  the  ring  which  constricts  it.  Then  compress  it  gently 
but  steadily  and  completely  with  the  hands  or  with  the  fingers  for  a  long 
time.  This  may  lessen  its  bulk.  By-and-by,  still  keeping  up  this  com- 
pression with  one  hand,  attempt  with  the  fingers  and  thumb  of  the  other 
to  manipulate  the  neck  of  the  hernial  tumor  back  into  the  abdomen.  It  is 
Baid  that  in  very  thin  persons  assistance  may  be  derived  from  insinuating 
the  finger  end  or  nail  beneath  one  edge  of  the  constricting  ring  and  pul- 
ling it  outward.  When  reduction  takes  place,  bowel  goes  back  suddenly 
with  a  gurgle.  Warm  bath,  average  time  twenty  minutes.  Laudanum, 
dose  twenty  minims.  Anaesthesia  not  only  makes  patient  insensible  to 
pain  of  proceedings,  but  destroys  any  muscular  resistance  that  he  might 
otherwise  make.  Practice  of  inverting  patient  during  performance  of 
taxis.     Aspiration  of  hernial  tumor  before  taxis. 

Herniotomy. — Usually  classed  as  1,  herniotomy  without  opening  sac  ;  2, 
herniotomy  with  opening  sac.  Both  operations  identical  up  to  a  certain 
point.  Scalpel,  forceps,  director,  artery  forceps,  ligatures,  retractors,  hernia 
director,  hernia  knife ;  strong  ligature  to  tie  omentum.  Empty  blad- 
der, shave,  line  of  incision  two  to  three  inches  long  over  neck  of  sac. 
Obsei-ve  the  position  of  certain  anatomical  landmarks,  e.g.,  spine  of  pubes, 
Poupart's  ligament,  femoral  artery.  Skin  may  be  divided  by  pinching  up 
and  transfixing.  Divide  fascia,  fat,  and  cellular  tissue  on  director,  layer 
by  layer  down  to  sac.  Before  opening  sac,  feel  for  any  constricting  bands 
external  to  sac  and  divide  them  if  possible.  If  strangulation  cannot  be  re- 
lieved thus,  proceed  to  open  sac  by  pinching  up  a  small  part  of  it  with 
forceps  and  cutting  it  with  knife  held  flatwise.  Complete  opening  of  sac 
on  a  director.  How  to  Distinguish  Sac  from  Intestine. — The  sac  is  a  trans- 
parent membrane  without  the  special  marks  possessed  by  intestine,  such 
as  arborescent  arrangement  of  vessels,  smooth,  glittei'ing  surface,  etc.  It  is 
also  thinner  than  intestine.  The  opening  of  the  sac  is  almost  always  re- 
cognized by  the  sudden  escape  of  fluid.     Division  of  Stricture. — Use  left 


HERNIA.  129 

index  finger  as  a  director,  insinuate  finger-nail  under  stricture,  pass  hernia 
kuife  flat,  along  palmar  surface  of  finger,  through  stricture,  then  turn  its 
edge  upward  and  slightly  inward  and  cut  one-eighth  to  one-quarter  of  an 
inch,  i.e.,  a  mere  notch,  no  more.  Reduction  of  the  hernia  is  then  effected 
by  manipulation  like  that  of  the  taxis.  If  necessary  the  knife  must  be  re- 
introduced and  the  constricting  band  notched  again.  But  there  are  certain 
conditions  under  which  it  is  not  right  to  reduce  the  hernia  after  dividing 
the  stricture.  It  follows,  of  com-se,  that  when  indications  of  these  condi- 
tions are  present  no  attempt  should  be  made  to  reduce  a  hernia  without 
opening  the  sac  to  see  the  actual  state  of  things.  Gangrenous  bowel,  bowel 
manifestly  ulcerated  at  the  seat  of  stricture,  and  omentum  inflamed  or 
bruised  should  not  be  returned  into  the  abdomen.  In  the  former  two  cases 
an  artificial  anus  will  form.  In  the  case  of  inflamed  omentum  its  return 
would  probably  set  up  general  peritonitis  ;  therefore  the  practice  is  to  tie 
a  stoiit  ligature  round  its  neck  and  cut  the  omentum  off,  merely  leaving  the 
neck  or  stump  of  it  to  block  up  the  hernial  ring.  Shght  wounds  of  the 
bowel  do  not  contraiudicate  its  reduction.  The  sides  of  a  puncture  can 
be  pinched  up  and  Hgatui-ed.  A  larger  wound  would  require  the  glover',s 
suture.  Characters  of  the  Serum  in  the  Sac. — 1.  Within  a  few  hours,  it  is 
pale  yellow  and  clear.  2.  After  many  hours,  it  becomes  dark  brown,  but 
clear.  3.  When  intestine  is  more  inflamed,  oedematous,  and  leather}',  the 
fluid  is  turbid  and  coffee-Hke.  4.  As  gangrene  approaches,  blood-clots, 
lymph-flakes,  and  pus  mix  with  the  fluid.  5,  When  intestine  gives  way, 
fseces  and  gas  escape.  Characters  of  the  Intestine  at  Different  Stages  of 
Strangulation. — First  stage.  Congestion,  various  degrees  from  mere  swell- 
ing and  redness  up  to  purple  color  with  patches  of  extravasation,  causing  a 
mottled  look.  Second  stage.  Inflammation,  same  appearances  as  those  of 
first  stage  ;  but  surface  is  dull  and  perhaps  adherent,  being  covered  wholly 
or  partially  with  lymph.  Third  stage.  Gangrene ;  more  adhesive  ;  siu'- 
face  duller ;  color  black  or  ashy ;  sloughing  and  perforation  about  to 
occur. 

Artificial  a)ius  results  when  herniated  bowel  sloughs  or  is  dehberately 
and  freely  opened  by  surgeon.  Possibility  of  former  event  happening 
even  a  week  after  reduction  of  hernia.  Then  adhesions  prevent  intra- 
peritoneal extravasation.  Pathology. — Two  openings,  one  into  intestine 
above,  other  into  intestine  below.  Former  tends  to  enlarge,  latter  to 
diminish.  Tendency  to  prolapsus  of  mucous  membrane.  Irritation  and 
excoriation  of  skin.  Spur  between  upper  and  lower  portions  of  bowel. 
Many  cases  recover  spontaneously.  When  opening  is  high  up  in  small 
intestine,  general  nutrition  suffers  considerably  b}'  escape  of  chyle.  Treat- 
ment.— Zinc  ointment  round  aperture  ;  bag  to  catch  fivces,  or  plug  to  retain 
them  temporarily  ;  cleanliness.  When  the  condition  persists,  operate. 
Divide  spur  gradually  with  Dupuytren's  enterotome  ;  division  should  oc- 
cupy several  days.  Then  close  ai'tificial  anus  with  hare -lip  pins,  after 
9 


130  HEENIA. 

paring  edges.  Fecal  fistula  is  a  very  mild  degree  of  artificial  anus,  which 
usually  closes  spontaneously.     Otherwise  treat  it  on  general  principles. 

Reduction  en  masse. — In  the  course  of  taxis,  hernia  disappears,  but 
symptoms  of  strangulation  come  on  or  remain.  Bowel  has  slipped,  not 
back  into  peritoneal  cavity,  but  sideways  between  peritoneum  and  muscles 
of  abdominal  wall.  Two  varieties  :  in  one,  bowel  bursts  through  a  hole  in 
neck  of  sac  ;  in  other,  sac  as  well  as  bowel  is  misplaced.  Signs. — If  surgeon 
himself  causes  the  misfortune,  he  notes  the  absence  of  that  sudden  jerk 
with  which  a  hernia  j)roperly  reduced  usually  disajDpears.  The  history 
of  the  case  points  to  the  occurrence.  Symptoms  of  strangulation  remain 
unrelieved.  Treatment. — Oj)erate ;  open  sac  ;  pull  bowel  out  of  its  mal- 
position ;  divide  stricture  and  reduce.  An  intra-parietal  sac,  a  diverticu- 
lum from  the  ordinary  sac,  sometimes  exists.  A  hernia  may  be  pushed 
into  it  instead  of  into  abdomen. 

After-treatment  of  Herniotomy. — Chiefly  negative.  Kest  in  bed  ;  liquid 
food  till  the  bowels  have  acted  ;  opium  unnecessary  ;  no  purgatives;  enema 
if  bowels  do  not  act  spontaneously  within  ten  days.  If  peritonitis  should 
arise,  it  must  be  treated  promptly  and  vigorously,  like  peritonitis  from 
other  causes. 

lEKEDucmLE  Hernia. — Caicscs. — 1,  Adhesion;  2,  neglect  of  reduction 
combined  with  hypertrophy  of  the  herniated  parts.  Adhesions  of  the  parts 
uncovered  by  peritonetun  make  all  hemiaj  of  the  bladder  and  crecum 
irreducible.  Omentum  is  apt  to  become  irreducible.  Treatment. — Gradual 
compression  by  a  bag  made  to  lace  up,  as  advised  by  Langton.  Combine 
this  with  pot.  iod.  internally. 

Special  Heeni^. — Birkett's  classification : 

I.  In  the  Epigastrium. — 1.  Diaphragmatic.     2.  Epigastric. 

n.  In  the  Mesogastrium. — 1.  Ventral  (also  in  other  regions).  2.  Umbili- 
cal.    3.  Lumbar. 

in.  In  the  Hypogastrium. — 1.  Inguino-scrotal  (labial  in  female).  2. 
Femoral.    3.  Obturator.  4.  Perineal.   5.  Pudendal.  6.  Vaginal.  7.  Ischiatic. 

Diaphragmatic  Hernia. — Three  kinds,  viz.:  1,  congenital,  left  leaflet  of 
centrum  tendineum  usually  absent ;  2,  ordinary,  abdominal  viscera  pass 
through  one  of  the  naturally  deficient  parts  of  the  diaphragm,  usually 
close  to  ensiform  cartilage  ;  3,  traumatic,  through  a  wound.  Birkett  adds 
to  these,  cases  of  relaxed  diaphragm  bulging  upward  from  pressure  of 
viscera  below.  Signs. — Malposition  of  viscera  may  be  detected  by  ausculta- 
tion and  percussion.  Occasionally  symptoms  of  obstruction,  strangulation, 
or  impeded  respiration.  Perhaps  history  of  accident. '  In  traumatic  and 
congenital  cases  there  is  no  sac.  Prognosis. — Traumatic  cases  usually  fatal. 
Others  may  never  even  be  suspected  during  hfe.     Treatment. — Nil. 

'  Tn  one  case  the  affected  side  of  thorax  was  disproportionately  large. — Gariik, 
Pathological  Transactions,  1879. 


HERNIA.  131 

Epigastric  and  Ventral  Hernia  are  to  be  recognized  and  treated  on  gen- 
eral principles. 

Umbilical  Hernia. — Appears  commonly  either  in  infants  or  fat  middle- 
aged  women.  Umbilical  hernia  in  infants,  though  termed  "congenital," 
differs  from  congenital  inguinal  hernia,  in  having  to  form  its  own  sac  by 
pushing  jDeritoneum  before  it.  Coverings. — Skin,  fat,  and  fascia  usually 
matted  together.  Neck  of  sac  thickened  and  strong.  Contents. — Various. 
Stomach,  smaU  intestine,  omentum.  Often  very  large.  Prognosis. — In 
infants  tendency  is  toward  spontaneous  cure.  Obstruction  a  more  com- 
mon accident  than  strangulation.  Treatment. — Cork  and  strapping  ;  pad 
and  bandage  ;  jjroper  trusses  or  abdominal  belts  for  severe  cases.  In 
operating  for  strangulation  divide  the  coverings  very  carefully.  See  also 
treatment  of  hernia  in  general,  above. 

Inguinal  Hernia. — Classification:  I.  Direct  or  internal.  11.  Oblique  or 
external,  including  (1)  common  or  scrotal,  (2)  congenital,  (3)  funicular, 
(4)  infantile.  Direct  comes  out  internal  to  deep  epigastric  artery,  i.e.,  in 
triangle  of  Hesselbach.  Oblique  descends  externally  to  deep  epigastric 
artery,  i.e.,  comes  down  inguinal  canal.  ^Common  scrotal  hernia  has  a  sac 
altogether  independent  of  tunica  vaginalis,  and  usually  lying  anterior  to  it. 
Congenital  has  for  its  sac  the  unclosed  tunica  vaginalis  testis.  Funicular. — 
"Hernia  into  the  funicular  process  of  the  j)eritoneum,"  occupies  the  fu- 
nicular portion  of  the  tunica  vaginalis,  which  peritoneal  process  has,  in  this 
case,  closed  only  at  or  near  the  external  abdominal  ring.  Infantile  or  Encysted 
Hernia. — This  occui'S  when  the  tunica  vaginalis  is  unobliterated  from  the 
testicle  wp  to  the  external  abdominal  ring.  The  sac  lies  envelojDed  in  the 
tunica  vaginalis.  "Hernia  en  bissao  "  ia  a  kind  of  congenital  hernia  in 
which  the  intestine  has  burst  through  a  constricted  part  of  the  tunica 
vaginalis.  The  tunica  vaginalis  may  have  been  completely  divided  by  a 
septum  at  the  seat  of  constriction  before  the  hernia  forced  its  way  down- 
ward. Bubonocele  is  an  inguinal  hernia  which  lies  wholly  in  the  inguinal 
<?anal.  Diagnosis  of  Congenital  from  the  Ordinary  Scrotal  Hernia. — Congenital 
hernia  occurs  in  children  and  yoiiths,  appears  suddenly,  descends  rapidly, 
and  envelops  testicle.  Ordinary  hernia  occurs  in  adult  age,  descends 
slowly,  and  is  separated  from  testicle.  Infantile  hernia,  etc.,  are  recognized 
after  death  or  during  operation.  In  operating  you  divide,  in  common 
scrotal  hernia,  congenital  hernia,  funicular  hernia,  hernia  en  bissac,  one 
serous  layer ;  in  infantile  or  encysted  hernia,  three  serous  layers.  In  con- 
genital hernia  testicle  is  found  in  sac.  Diagnosis  of  Hernia  from  other 
Inguinal  and  Scrotal  Swellings. — A.  Inguinal  swellings. — 1.  Encysted  hydro- 
cele of  cord,  though  often  reducible,  is  otherwise  altogether  unlike  a  hernia,  ~ 
being  transparent,  oval,  very  defined,  and  tense.  2.  Undescended  testis. 
Testis  is,  of  course,  absent  from  scrotum.  It  gives  the  characteristic  j)ain 
on  pressure,  and  is  irreducible.  Inflamed  testis  in  this  situation  causes 
symptoms  like  those  of  strangulated  hernia.     Still  the  vomiting  is  jpei'- 


132  HEENIA. 

sistent  and  continuous,  not  gushing.  Diffused  hydrocele  of  the  cord, 
hsematocele  of  the  cord,  tumors  of  the  cord,  may,  like  elephantiasis  scroti, 
be  left  to  the  surgeon's  common  surgical  knowledge  and  common  sense. 
B.  Sci'otal  swellings. — 1.  Ordinary  hydrocele.  Begins  at  bottom  of  scrotum, 
has  usually  no  neck  extending  up  into  inguinal  canal,  is  tense  or  fluctuat- 
ing, transparent,  without  impulse,  and  generally  of  characteristic  pyriform 
or  oval  shape.  But  hernia  and  hydrocele  may  coexist.  2.  Hematocele. 
Cord  defined,  no  impulse.  Perhaps  ecchymosis.  3.  Varicocele.  Worm- 
like feel.  Though  reducible  when  patient  is  recumbent,  yet  appears  again 
when  he  stands  up,  in  spite  of  finger  placed  over  inguinal  ring.  4.  Tumors 
of  testis.  Cord  may  be  thickened  but  is  usually  clear.  Testis  itself  in- 
volved. Tumor  heavv^  opaque,  perhaps  hard  and  irregular.  Of  course  no 
impulse.  Often  pain.  Treatment. — See  that  of  hernia  in  general.  Pad 
of  truss  should  cover  whole  of  inguinal  canal  in  oblique  inguinal  hernia, 
and  should  never  compress  cord  against  pubes.  In  operating  for  strangula- 
tion, constriction  is  mostly  found  either  at  neck  of  sac  or  at  external  ab- 
dominal ring. 

Femoral  Hernia. — Hernia  into  the  crural  sheath.  Almost  always  comes 
through  femoral,  i.e.,  crtu'al,  ring.  In  a  few  rare  cases  has  been  seen  ex- 
ternal to  femoral  vessels.  Occurs  much  more  in  women  than  in  men. 
But  it  must  not  be  thought  that  inguinal  hernia  is  uncommon  in  women. 
In  childhood  and  youth,  hernia  in  females  is  almost  always  inguinal ;  after 
forty  years  of  age  it  is  usually  femoral.  For  coverings,  relations,  etc.,  vide 
books  on  anatomy.  Signs. — General  characteristics  of  hernia.  Situation 
of  tumor :  it  apjoears  below  Poupart's  ligament,  just  external  to  spine  of 
pubes,  and,  though  at  first  descending,  eventually  turns  upward  and  out- 
vrard  in  a  direction  parallel  to  Poupart's  Hgament..  Femoral  hernia  is  not 
large  usually,  but  occasionally  attains  an  enormous  size.  Diagnosis. — 
Sometimes  difficult.  From  1,  enlarged  glands  ;  2,  psoas  abscess  ;  3,  varix 
of  saphena.  Enlarged  glands  have  no  impulse,  are  often  multiple,  may 
have  an  obvious  cause,  e.g.,  an  inflamed  bunion.  Also  they  can  usually  be 
felt  to  have  no  base  like  the  neck  of  a  hernial  tumor.  In  psoas  abscess 
fluctuation  can  often  be  produced  from  one  side  of  Poupart's  ligament  to 
the  other,  that  is  fi'om  the  thigh  to  the  abdomen,  and  vice  versd.  It  cannot 
be  reduced  with  a  gurgle  like  a  hernia.  Manifest  spinal  disease  may  co- 
exist. Varix  probably  extends  some  distance  dov\Ti  saphena ;  and,  though 
reducible  in  the  horizontal  posture,  it  rapidly  returns  in  the  erect,  in  spite 
of  the  finger  placed  over  the  ciniral  ring.  Femoral  and  inguinal  hernia? 
are  distinguished  fi-om  each  other  by  theu'  relations  to  Poupart's  ligament 
and  the  pubic  spine,  and  by  the  state  in  which  the  inguinal  and  cinrral 
rings  are  found.  Although  a  femoral  hernia  may  ascend,  yet  its  neck  is 
always  below  Pouparfs  ligament.  Prognosis, — Femoral  hernia,  very  liable 
to  acute  and  fatal  strangulation.  Treatment. — Best  truss  probably  moc- 
main.     In  case  of  strangulation,  flex  and  abduct  thigh  diuring  taxis.     In 


HIP   DISEASE.  133 

oijerating,  cut  upward.  Notch  slightly  because  of  danger  of  wounding 
abnormal  obturator  artery.  Seat  of  stricture  may  be  falciform  jDrocess  of 
Burns,  Gimbernat's  ligament,  deep  crural  arch,  or  neck  of  sac  itself.  Use 
of  term  "Hey's  ligament"  ought  to  be  abolished  as  unnecessary  and  con- 
fusing. 

Obturator  Hernia. — Very  rai^e.  /Sigrws  obscure.  Fulness  below  Pou]part's 
ligament,  beneath  rather  than  internal  to  femoral  vessels.  Pain  down 
inner  side  of  thigh.  Femoral  ring  found  normal.  Age  of  j^atient  usually 
advanced.  "Symptoms  of  obturator  hernia  may  be  those  of  chronic  ob- 
struction associated  with  emaciation." — Goodhart:  "Pathological  Transac- 
tions," 1876.  Operation  for  strangulation  would  be  conducted  on  general 
princiiDles  with  due  care  of  blood-vessels.  It  would  resemble  that  for 
femoral  hernia,  but  fascia  lata  and  pectineus  would  require  incision. 

Herpes. — A  dermatitis  resembling  eczema,  but  different  from  it  be- 
cause the  vesicular  eruption  is  more  marked  and  the  actual  cutaneous  in- 
flammation less  marked  than  in  eczema,  and  also  because  it  runs  a  cyclical 
course.  Classified  according  to  locality  into  herpes  labiaHs,  herpes  pre- 
putialis,  etc.,  and  according  to  form  into  common  herpes,  herpes  cu'cinatus, 
herjies  ii'is,  herpes  zoster.  Causes. — Nervous  origin  of  herpes  zoster,  con- 
nection of  herpes  facialis  with  influenza  and  pneumonia,  and  of  herpes 
preputialis  with  temporary  local  u-ritation.  (Eczema  arises  mostly  from 
chronic  irritation.)  Signs. — See  definition.  Vesicles  ajjpear  in  successive 
crops,  their  contents  grow  turbid,  then  scabs  form.  These  scabs  fall  off 
within  a  fortnight.  Burning  pain.  Febrile  disturbance.  Eruption  may 
corresi^ond  to  distribution  of  some  nerve.  Herpes  iris  and  circiuatus 
have  smaller  vesicles,  spread  concentrically,  desquamate  instead  of  scabbing, 
and  are  usually  of  parasitic  origin.  Treatment. — Soothing  and  protective. 
Cotton  wool  for  herpes  zoster.  Zinc  ointment  for  herpes  preputiaHs.  For 
herpes  circinatus  (ring-worm),  blistering  fluid,  which  should  be  apjDlied 
quickly  and  then  washed  off  at  once  with  water.  Ung.  hydrarg.  ammon., 
or  tinct.  iodi.,  or  lin.  crotonis.     See  Alder  Smith,  on  "  Eing-Worm." 

Hip  Disease. — Morbus  coxse.  Disease  of  hip-joint.  Causes. — Pi-e- 
disposing  are  scrofula  and  the  ages  of  childhood  and  early  youth.  EscitJhg 
are  local  injuries,  often  very  sUght,  and  exposure  to  cold.  Cause  often  un- 
certain. Affections  of  the  generative  organs  sometimes  cause  hip  disease, 
probably  in  a  reflex  manner.  Varieties. — Hip  disease  has  been  divided 
anatomically  according  as  it  affects  the  femiir  only  or  the  acetabulum.  In 
many  cases  both  are  involved.  Also  it  may  be  acute,  subacute,  or  chi'onic. 
Or  it  may  be  strumous  or  purely  traumatic  or  rheumatic  in  origin.  Prac- 
tically it  is  rarely  possible  to  say  whether  a  given  case  is  or  is  not  strumous. 
Some  diseases  of  the  hip-joint,  e.g.,  chronic  rheumatic  arthritis,  never 
have  the  term  "  hip  disease  "  applied  to  them.  Symptoms. — Three  stages  : 
1st,  inflammatory  ;  2d,  stage  of  abscess  ;  3d,  stage  of  real  shortening.  In- 
flammatory stage.     Before  the  symptoms  are  well  marked,  the  term  "  in- 


134  HIP   DISEASE. 

cipient"  is  used.  Stiffness  of  joint.  When  patient  lies  on  his  back  his 
knee  is  bent  upward.  If  an  attempt  be  made  to  straighten  it,  the  small 
of  his  back  becomes  hollow,  because  the .  pelvis  moves  with  the  femur. 
Wasting  of  limb,  often  a  very  early  spnptom :  flattening  of  buttock  and 
obliteration  of  gluteal  fold.  Pain  often  referred  to  inner  side  of  knee. 
Pain  is  most  severe  when  disease  begins  in  the  bone.  Fulness  over  joint, 
best  marked  when  disease  begins  in  synovial  membrane.  Apparent  leng- 
thening, sometimes  apparent  shortening,  both  due  to  rocking  of  pelvis. 
Very  rarely  real  lengthening,  due  to  effusion  into  joint.  Of  course  the 
patient  limps.  2d  stage.  Stage  of  abscess.  The  suppuration  is  some- 
times entii'ely  outside  joint.  Pus  burrows,  fluctuation  occurs,  sometimes  in 
one  place,  sometimes  in  another ;  sinuses  form.  Probe  very  likely  fails  to 
find  dead  bone.  SajTc's  vertebrated  j)i'obe  useful.  Situation  of  sinuses 
indicates  situation  of  disease,  whether  acetabular  or  femoral  {see  "  Path- 
ology ").  Before  abscess  opens,  3d  stage  has  usually  commenced.  3d  stage. 
Stage  of  real  shortening.  This  results  from  the  gi-adual  destruction  of  head 
and  neck  of  femur  by  caries  or  necrosis,  usually  by  caries.  Top  of  tro- 
chanter ascends  above  Nelaton's  line,  a  line  drawn  from  ant.  sup.  spine  of 
ilium  to  tuberosity  of  ischium.  Abscesses  or  sinuses,  lordosis,  flexion  of 
thigh  on  abdomen,  wasting  of  buttock  and  thigh  and  pain  continue  as  in 
former  stages.  The  disease  naturally  terminates  either  in  death  from  ex- 
haustion or  amyloid  disease,  or  in  recovery  witli  ankylosis.  The  ankylo- 
sis is  in  the  flexed  position  and  accompanied  by  a  compensatory  si^inal 
curve  of  the  kind  called  lordosis. 

Pathology. — Disease  may  begin  either  (1)  in  the  bone  near  the  joint,  or 
(2)  in  the  soft  tissues,  synovial  membranes,  or  ligaments  of  the  joint.  In 
the  latter  case  the  disease  is  sometimes  named  "  arthritic."  It  is  a  gener- 
ally accepted  doctrine  now  that  the  only  joint  disease  which  begins  in  the 
cartilage  is  chronic  rheamatic  arthritis.  For  a  description  of  the  general 
changes  which  take  j)lace  in  hip  disease,  see  Diseases  of  Bones  and  of 
Joints.  Ligamentum  teres  soon  gives  way.  Head  of  femiu-  perishe's  by 
caries  or  by  necrosis.  If  acetabulum  is  affected,  it  is  apt  to  perish  par- 
tially by  necrosis,  often  becoming  perforated.  Even  when  head  of  femur 
is  destroyed  remains  of  neck  of  femur  rarely  leave  acetabulum.  True  dis- 
location on  dorsum  ilii  does  occasionally  occur,  or,  acetabulum  being  per- 
forated, head  of  femur  may  shp  through  into  pelvis.  The  natural  tendency 
is  toward  a  cure  by  ankylosis.  In  acetabular  disease,  sinuses  usually  form 
in  buttock,  or  close  to  pubes.  In  femoral  disease  they  usually  ojjen  lower 
down  thigh,  especially  below  and  in  front  of  great  trochanter.  Diagnosis. 
— Most  cases  of  hip  disease  are  unmistakable.  Sometimes  difficult  to  dis- 
tinguish incipient  hip  disease  from  other  affections  which  cause  pain  about 
the  hip,  accompanied  by  lameness,  common  rheumatism  for  example.  In 
fact  many  cases  of  hij)  disease  do  actually  begin  as  rheumatic  synovitis. 
No  disease  of  the  parts  about  the  hip  causes  such  stiffness  of  the  joint : 


HIP   DISEASE.  135 

that  is  a  great  point.  Pain  in  the  knee  may  lead  off  the  attention  to  the 
wrong  place.  Many  affections,  e.g.,  curvature  of  spine  and  hysteria,  cause 
rocking  of  pelvis  and  apparent  shortening  or  lengthening.  In  healthy 
people,  the  lower  extremities  are  often  slightly  unsymmetrical. '  But  in 
such  jjersons  if  one  leg  is  much  shorter  than  the  other,  the  feet  will  prob- 
ably also  be  disproportioned.  Comparative  measurements  should  be  taken 
from  ant.  sup.  sj)ine  of  ilia  to  upper  or  lower  end  of  patella  or  to  inner 
malleoli.  Nelaton's  line,  Bryant's  ilio-femoral  triangle.  Bryant's  ilio- 
femoral triangle  is  formed  by  a  horizontal  line  across  top  of  trochanter,  a 
perpendicular  line  from  ant.  sup.  iliac  spine  downward,  and  an  oblique 
line  from  ant.  sup.  iliac  spine  to  top  of  trochanter.  The  Hues  are  equal 
on  both  sides  in  normal  persons.  Enlarged  bursa  under  psoas  is  very 
rare  ;  and  the  pain,  if  present,  is  relieved  not  aggravated  by  flexing  thigh 
on  abdomen.  Hip-joint  disease  could  hardly  be  accompanied  by  such 
marked  swelling  over  the  joint  without  presenting  characteristic  and 
marked  symptoms.  Hysteria  must  be  diagnosed  on  general  principles. 
*S'ee  Hysterical  Diseases  of  Joints.  It  would  really  be  a  waste  of  space  to 
give  the  diagnosis  of  hip  disease  from  psoas  abscess,  sacro-iliac  disease, 
and  congenital  dislocation  ;  for  it  may  be  assumed  that  the  surgeon  will 
not  try  to  diagnose  a  doubtful  case  without  taking  the  patient's  clothes  off^ 
and  manij)ulating  carefully.  Prognosin  depends  on  stage  of  disease,  origi- 
nal constitution  of  patient,  jDresent  condition  of  j)atient,  on  parts  actually 
diseased,  and  on  age  of  patient.  In  first  stage  of  disease,  especially  if 
symptoms  point  to  origin  in  joint  itself,  treatment  may  be  expected  to  re- 
sult in  recovery  with  or  without  ankylosis  in  good  j)osition.  Scrofulous 
patients  are  very  likely  to  become  tuberculous  elsewhere  when  the  bone  is 
affected.  When  necrosis  or  caries  has  occurred,  jDrognosis  is  very  bad  as 
to  life.  It  is  worse  in  adults  with  acetabular  disease.  The  only  cases  in 
which  recovery  without  ankylosis  is  to  be  reasonably  looked  for  are  those 
in  which  the  cartilage  and  bone  have  never  been  affected.  Treatment. — 
Eest  of  the  joint  essential.  Sayre's  splint  is  supposed  to  make  rest  in  bed 
unnecessary  in  many  cases  in  which  the  disease  has  not  too  far  advanced. 
Extension  by  pulleys  and  weights  (3  to  10  lbs.,  according  to  age  and  indi- 
vidual peculiarity  of  patient).  Long  splint  (long  splint  on  sound  side, 
weight  to  diseased  limb)  ;  Thomas'  sjDlint,  plaster  cases,  leather  cases,  etc. 
Treatment  should  be  continued  so  long  as  there  is  any  tenderness  or  sign 
of  active  disease  and  for  a  little  longer.  Limb  should  be  straightened 
under  chloroform,  if  weight  fails  to  bring  it  down  gradually  and  easily. 
Inflammatory  reaction  after  this  manipulation  may  be  treated  by  ice  or  by 
hot  poultice  locally,  according  to  which  seems  to  act  best.  When  there 
are  signs  of  struma,  give  cod-liver  oil  and  iron.  In  suppui-ative  stage,  treat 
abscesses  and  sinuses  on  general  principles.    Question  of  Excision.^-When 

'  See  Garson,  Journal  Anatomy  and  Physics.  1880. 


136  HYDROCELE. 

suppuration  continues,  patient's  exhaustion  increases,  and  there  is  evidence 
of  bone  disease  ;  and,  especially  if  the  patient's  circumstances  are  so  poor 
that  he  cannot  get  proper  attention  during  long  rest  in  bed,  the  surgeon 
is  justified  in  operating  to  remove  the  dead  bone.  Still  the  operation  has 
its  dangers,  and  the  resulting  limb  is  likely  to  be  shorter  than  after  the 
natural  cure.  Moreover  it  is  very  difficult,  sometimes  impossible,  to  thor- 
oughly remove  pelvic  necrosis.     For  operation,  vide  article  Excision. 

Horns. —  Vide  Waets. 

Housemaid's  Knee. — See  Buks^,  Enlarged. 

Hydatids  occur  in  bones,  breast,  muscles,  and  other  parts,  and,  in 
surgery,  are  rarely  diagnosed  from  other  cysts  till  operation  has  let  out 
hooklets,  etc. 

Hydrocele. — An  accumulation  of  serum  forming  a  swelling  in  connec- 
tion with  the  testicle  or  spermatic  cord.  Varieties. — 1.  Hydrocele  of  the 
tunica  vaginalis  testis  (common  hydrocele).  2.  Hydrocele  of  the  cord 
(sometimes  called  "  encysted  hydrocele  of  the  cord  ").  3.  Encysted  hy- 
drocele (frequently  called  "  encysted  hydrocele  of  the  epididj-mis,"  or  "  of 
the'  testicle  ").  4.  Diffused  hydrocele  of  the  cord.  5.  Congenital  hydro- 
cele.    6.  Infantile  hydrocele. 

Hydrocele  of  the  Tunica  Vaginalis  Testis. —  Causes. — Middle  age,  weak 
constitution,  and  gout  predispose.  Injury  and  orchitis  excite.  In  most 
cases  there  has  been  no  knoAvn  exciting  cause.  Signs. — A  scrotal  tumor, 
smooth,  oval,  pyriform,  or  globular  (often  constricted  in  the  middle);  elas- 
tic, tense  or  fluctuating,  transparent  or  semi-transi^arent  (rarely  quite 
opaque).  No  connection  with  abdomen.  Cord  free  near  abdominal  ring. 
No  impulse  on  coughing.  Penis  gets  "absorbed,"  as  it  were,  into  tumor. 
Diagnosis. —  Vide  Hematocele  and  Inguinal  Heenia.  Treatment. — 1,  Pallia- 
tive ;  2,  radical  cure.  Palliative  =  tapping  wdth  trochar  and  canula,  or  mere 
use  of  discutient  lotions  +  suspensory  bandage.  In  tapping,  make  out 
position  of  testicle  by  jDalpation,  by  assistance  of  patient's  sensations,  and 
by  use  of  candle  and  stethoscope.  Grasp  tumor  firmly  in  left  hand,  so 
that  testicle  lies  in  centre  of  left  palm.  Plunge  trochar  obliquely  upward 
and  backward  into  junction  of  middle  and  lower  thirds  of  hydrocele.  The 
fluid  usually  collects  again.  Lotio  ammonias  hydrochlor.  (3j.  to  3VJ.) 
used  as  a  discutient.  Eadical  cure. — First  empty  the  hydrocele,  then  in- 
ject two  drachms  of  port  wine  or  of  tinct.  iodi  and  water,  equal  parts.  Let 
the  injection  flow  out  after  a  minute  or  two.  Platinum  canula  shovdd  be 
used  for  tinct.  iodi.  Lewis  recommends  carbolic  acid  and  glycerine,  aa 
3  ss.,  instead  of  iodine,  and  says  it  is  less  painful.  Treatment  by  seton 
not  to  be  recommended.  After-treatment. — Bed  for  two  or  three  days. 
Pathology. — A  serous  dropsy  of  the  tunica  vaginalis,  probably  of  chronic 
inflammatory  origin.  The  radical  cure  acts  by  checking  the  secretion  of 
the  tunica  vaginalis,  and  rarely  results  in  the  production  of  adhesions. 

Hydrocele  of  the  Cord. — Its  pathology  is  probably  that  of  a  dropsy  of  a 


HYDROPHOBIA.  137 

small  unobliterated  part  of  tlie  tunica  vaginalis  funiculi.  It  may  some- 
times be  an  independent  cyst.  Its  appearances  are  quite  characteristic. 
It«is  transparent,  feels  like  a  pigeon's  egg,  only  more  elastic,  and  slips  up 
and  down  between  the  fingers  with  great  mobility.  You  may  fancy  that 
you  have  reduced  it  into  the  inguinal  canal,  when  suddenly,  in  a  humor- 
ous way,  it  may  be  discovered  half-way  down  the  cord  toward  the  testicle. 
Occurs  in  the  young.  Diagnosis. — Only  in  rare  cases,  when  it  extends 
right  into  inguinal  canal,  and  patient  is  so  fat  as  to  hide  transparency,  can 
this  aifection  be  mistaken  for  a  hernia.  Treatment. — Tap  and  inject  with 
tiuct.  iodi  and  water,  equal  parts.  Before  injecting  be  sure  that  the  case 
is  not  one  of  "  congenital "  hydrocele. 

Encysted  Hydrocele. — Signs. — Those  of  cyst  attached  to  the  testicle, 
usually  to  the  head  of  the  epididymis.  Pathology. — A  cyst  containing 
sometimes  pure  serum,  but  fi-equently  a  mixtiu-e  of  serum  and  seminal 
fluid.  An  opening  has  often  been  found  between  the  seminal  tubules  and 
the  cyst.  The  cyst  may  originate  fi-om  a  dilated  seminal  tubule,  or  from 
a  dilated  cavity  in  the  connective  tissue,  or,  according  to  Osborne,  from 
enlargement  of  the  "hydatid  of  Morgagni."  Treatment. — Same  as  that  of 
ordinary  hydrocele. 

Diffused  Hydrocele  of  Cord. — Unknown  to  living  surgeons.  Described 
by  Pott.  But  hydrocele  of  cord  sometimes  receives  this  name  if  it  forms 
a  long,  rather  ill-defined  tumor. 

Congenital  Hydrocele. — Tunica  vaginalis  funiculi  is  open,  as  in  hernia, 
into  tunica  vaginahs  testis,  but  the  oj^en  process  contains  peritoneal  fluid 
instead  of  intestine.  Treatment. — Puncture  with  fine  trochar,  and  then  try 
to  close  the  opening  by  the  pressure  of  a  truss. 

Infantile  Hydrocele. — Occurs  in  infants  in  whom  tunica  vaginahs  has 
only  closed  at  external  abdominal  ring.  Treatment. — Discutient  lotions. 
Puncture.  If  it  is  certain  that  there  is  no  communication  with  peritoneal 
cavity,  iodine  injection  may  be  employed  in  obstinate  cases.  Many  cases 
disappear  with  veiy  httle  treatment. 

Hydrophobia. — A  disease  which  develops  primarily  only  in  the  dog, 
and  from  unknown  causes  ;  but  which  is  communicable  by  inoculation  with 
the  saliva  of  dog,  cat,  man,  or  any  other  animal  who  may  suffer  from  it. 

Symptoms  in  Dog. — Two  forms  (or  two  stages?),  viz.:  1,  a  raving  mad- 
ness ;  2,  a  quiet  madness.  Certainly  these  stages  do  sometimes  follow 
each  other  in  the  same  dog.  Or  three  stages  may  be  distinguished :  1,  of 
dulness  with  restlessness  ;  2,  of  fury  ;  3,  of  paralysis.  In  the  first  stage 
the  animal  wanders  about  in  a  fidgety,  uncomfortable  manner,  is  evidently 
ill,  and  looks  suspicious,  unhappy,  and  distrustful.  In  the  second  stage, 
much  of  the  fury  is  evidently  due  to  hallucinations.  He  bites,  but  it  is 
often  at  imaginary  enemies,  and  he  may  stiU  be  mindful  of  his  master's 
voica  In  the  third  stage,  paralysis  makes  the  voice  mufiled  or  inaudible, 
the  jaw  drops,  and  the  legs  totter  and  fail.     Finally  death  comes  from  ex- 


138  HYPEETEOPHY. 

haustion.  The  mad  dog  rarely  shuns  water,  but  laps  it  without  swallow- 
ing. 

Hydrophobia  in  3Ian. — Proportion  of  bitten  cases  attacked,  estimated 
f  by  Trousseau  at  one  in  two,  by  BiUroth  at  one  in  twenty  !  Period  of  in- 
cubation :  six  weeks  to  more  than  a  year.  Karely  less  than  six  weeks. 
Si/m23toms. — Firstly,  great  irritability,  excitement,  and  restlessness.  Spasms 
on  attempting  to  swallow  occur  sometimes,  but  rarely,  in  this  stage.  Ii-rita- 
bility  and  sensitiveness  to  Ught,  sound,  etc.,  increase  and  become  excessive. 
Soon  the  shghtest  causes  jaroduce  spasms.  Then  gradually  comes  the  fear 
of  water,  together  with  unspeakable  thirst.  Sleeplessness.  Terror  of  the 
sj)asms  and  theii*  causes.  Actual  madness  occurs  rarely.  Appearance  of 
most  fearful  anxiety.  Hoarseness.  Frothing  at  the  mouth.  Severe  tetanic 
spasms  now,  from  time  to  time,  suspend  resj)iration  ;  and,  finally,  in  one 
of  these,  the  patient  dies  asphyxiated.  Note  the  different  ways  in  which 
death  occurs  in  the  dog  and  in  man,  for  in  the  former  it  comes  by  ex- 
haustion. Diagnosis. — 1.  From  tetanus.  In  tetanus  there  is  a  certain 
amount  of  persistent  spasm,  in  hydrophobia  there  are  intervals  of  complete 
relaxation.  Tetanus  is  also  a  quiet  disease,  so  to  speak,  and  is  unac- 
companied by  horror  of  water,  even  although  the  sufferer  may  be  unable 
to  drink.  2.  From  hysteric  or  nexu'omimetic  hydi'ophobia.  In  the  sham 
disease  there  is  dysphagia,  but  no  alarming  spasm  of  the  respu-atory  mus- 
cles. Prognosis. — Hopeless.  Pathology. — Congestion  of  spinal  cord  has 
been  obsei-ved  with  collection  of  leucocytes  around  the  caj)iUaries.  Treat- 
ment. — All  remedies  hitherto  tried  have  been  vain.  Suffering  may  be 
alleviated  by  rest,  darkness,  and  perhaps  by  anaesthetics.  Try  tracheotomy. 
With  regard  to  proj)hylaxis,  cauterization  should  be  done,  early  if  possible, 
but  better  late  than  never.  Surgeons  of  great  ability  have  named  various 
limits  of  time  at  which  they  say  cauterization  ceases  to  be  of  any  use. 
These  limits  differ  considerably,  and,  in  my  humble  opinion,  it  has  yet  to 
be  shown  on  what  sufficient  grounds  they  have  been  fixed.  One  may  ask 
for  demonstration  that  the  poison  does  not  remain  near  the  wound  during 
the  period  of  incubation.  Cauterization  may  be  painful  and  obnoxious  ; 
but  what  are  these  considerations  when  compared  with  the  faintest  chance 
of  preventing  the  most  horrible  of  diseases?  Vesicles  ("lyssi")  aj^pear 
near  frsenum  linguge  between  third  and  twentieth  day  after  bite.  It  has 
been  recommended  to  examine  patient  twice  a  day  during  this  period, 
and  lay  open  and  cauterize  the  lyssi  as  they  appear.  Trousseau  supports 
this  recommendation. 

Hypertrophy. — Increase  in  size  of  the  tissues  of  a  part,  not  the  mere 
natural  result  of  growth  in  youth.  Sometimes  accompanied  by  increased 
development  of  the  individual  microscopic  constituents  of  the  tissue  :  e.g., 
when  the  gravid  uterus  enlarges,  the  individual  muscle-ceUs  also  grow. 
Causes.  —  Exercise,  irritation,  hyj)ersemia,  general  over-feeding,  sj^ecial 
over-feeding,  certain  special  diseases.     Irritation  may  be  direct  or  indirect. 


HYSTERIA.  139 

An  example  of  indii'ect  irritation  as  a  cause  is  liypertropliy  of  breast  from 
uterine  irritation.  Ii-ritation  certainly  acts  partially,  if  not  wholly,  by  pro- 
ducing bypertemia  tbrougb  reflex  inhibition  of  vaso-motor  system.  By 
si^ecial  over-feeding  is  meant  the  excessive  deposit  of  fat  which  may  result 
from  taking  fat-forming  food  to  excess.  As  examples  of  hypertrophy  from 
special  diseases,  may  be  cited  the  large  joints  of  rickety  childi-en  and  the 
thickened  skin  in  elephantiasis  scroti.  Treatment. — Remove  cause.  Favor 
venous  circulation.  Pressure.  Treat  special  diseases.  Operative  meas- 
ures. Vide  various  articles  in  this  book  on  hyjjertrophy  of  j)articular  or- 
gans and  parts. 

Hysteria. — Hysteria  is,  according  to  custom,  held  to  be  in  the  prov- 
ince of  the  physician,  and  the  surgeon  is  called  in  when  "this  protean 
malady  "  assumes  the  outward  form  of  sui-gical  disease.  Hence  the  best 
general  articles  on  hysteria  are  to  be  found  in  medical  treatises.  From 
the  surgeon's  point  of  view,  Mr.  Savory  treats  the  subject  graphically  in 
Holmes's  "  System,"  vol.  i.  Its  essential  nature.  Paget  has  called  it 
"madness  of  the  spinal  cord;"  but  its  phenomena  are,  perhaj)S,  more 
easily  explained  on  the  sujDposition  that  it  arises  from  "a  nutritive  de- 
rangement of  the  general  nervous  system,  both  central  and  peripheral." 
(Hasse,  as  quoted  by  Niemeyei').  Causes. — No  doubt  a  congenital  predis- 
jiosition  often  exists.  In  most  cases  there  is  certainly  to  be  found  an  ex- 
cituig  cause  in  the  form  of  chronic  irritation  of  some  system  or  organ  of 
the  body,  usually  the  genital  organs.  Uterine  infarctions,  ulcerations,  and 
flexions.  Ovarian  diseases.  Abnormal  sexual  irritation,  onanism.  If  you 
want  to  cure  your  patient,  do  not  let  modesty  or  benevolent  behef  in  hu- 
man nature  bhnd  you.  Do  not  ignore  those  causes  which  undoubtedly  sec- 
ond what  is  usually  the  prime  cause ;  but  there  is  much  less  fear  of  this 
error  than  of  the  error  which  consists  in  being  satisfied  with  the  discovery 
of  some  psychical  explanation  of  a  given  case,  e.g.,  excessive  intellectual  ex- 
ertion, or  unhappy  married  life.  The  sm-geou  must  judge  the  causation 
from  objective  symj)toms.  SHght  degrees  of  hysteria  are  not  at  all  uncom- 
mon in  men  ;  but  almost  all  marked  cases  occur  in  women.  Usual  age  from 
twelfth  year  to  twentieth,  and  again  at  the  "change  of  life."  Sedentary 
occupation.  Town  life.  Bad  training  in  childhood.  Signs. — 1.  Derange- 
ments of  sensibility.  General  hypercesthesia,  "  nervousness."  Great  acute- 
ness  of  the  senses.  Idiosyncrasies.  Desires  for  peculiar  foods,  objections 
to  common  foods,  etc.  Neui'algias.  Painful  and  tender  breasts,  migraine, 
face-ache,  and  other  pains.  Clavus  hystericus — that  is,  pain  in  one  small 
point  in  the  head.  Tenderness  of  the  back.  Severe  pains  and  exquisite 
tenderness  in  some  joint  or  other.  In  contrast  with  above  symptoms  are 
the  frequent  cases  of  real  or  pretended  ana?sthesia.  Difficult  to  tell 
whether  some  cases  of  hysterical  anaesthesia  are  real  or  sham.  Unnatural 
consciousness  of  the  actions  of  healthy  organs  of  the  body.  Palpitations. 
Sense  of  weight  in  epigastrium  dui'ing  digestion.     Great  thirst.     Frequent 


140  IMPETIGO. 

desire  to  pass  water.  2.  Hysterical  convulsions.  These  vary  in  intensity 
from  slight  local  spasnis  to  severe  general  spasms  with  opisthotonos  or 
other  convulsive  curvature  of  the  spine.  In  these  attacks  patient  never 
loses  consciousness.  Yawning,  laughing,  crying,  globus  hystericus.  Eruc- 
tations. 3.  Curvatui'e  of  the  spine.  Affections  of  joints.  4.  Derange- 
ments of  vaso-motor  system.  Cold  hands  and  feet.  Sudden  and  prolonged 
flushing  of  the  face.  Hypersemia  of  kidney,  causing  large  flow  of  limpid 
urine,  "  urina  spastica."  5.  Mental  symptoms.  Rapid  alternations  between 
grave  and  gay.  General  tendency  is  toward  depression.  Craviug  for  sym- 
pathy. It  is  this  craving,  probably,  which  produces  a  tendency  to  exagge- 
ration and  malingering.  Of  course  all  the  above  remarkable  symptoms 
cannot  be  looked  for  in  the  same  case.  Diagnosis. — Hysteric  imitations  of 
organic  disease  are  always  imperfect ;  because  hysteria,  if  one  may  be 
allowed  to  personify  it,  is  quite  ignorant  of  pathology  and  knows  little  of 
anatomy.  Hence  paiu  rarely  confines  itself  with  accui-acy  to  any  defined 
anatomical  structure  or  region.  In  hysteric  joint  affections  the  skin  over 
the  joint  is  often  exquisitely  tender,  while  deep,  firm  pressure  uj^on  the 
joint  itself  may  cause  Uttle  or  no  pain.  At  the  same  time  the  limits  of 
that  portion  of  skin  which  is  tender  bear  no  relation  to  the  distribution  of 
any  known  nerve  or  vessel.  Subjective  symptoms  last  even  for  years  with- 
out producing  any  corresponding  alterations  in  the  structui'e  of  the  affected 
part.  A  hysterical  patient  describes  her  suflerings  in  a  characteristic  way. 
It  is  not  difficult  to  make  her  smile  and  talk  with  cheerfulness  and  liveli- 
ness even  when  the  subject  is  x>ain  which  she  describes  as  "agonizing," 
"unendurable,"  "excruciating."  Hysteric  spasms  disappear  imder  anaes- 
thetics and  often  also  during  sleep.  There  are,  also,  concomitant  general 
signs  of  hysteria.  Prognosis. — Some  cases  of  hysteria  resist  all  treatment. 
Many  of  these  have  one  foot  across  the  narrow  line  which  separates  hysteria 
from  insanity.  Treatment. — Treat  the  cause,  whatever  that  may  be.  Moral 
treatment :  encourage  and  lead  the  patient  to  exercise  her  will.  Hysteria 
often  attacks  persons  who  have  never  in  childhood  been  taught  to  con- 
trol themselves.  Sea-bathing,  cold  shower-baths,  early  rising,  open-air  hfe, 
tonics,  bromide  of  potassium.  "Antispasmodics,"  valerian,  asafoetida. 
Electricity  is  invaluable  in  treating  many  neuro mimetic  [i.e.,  hj^steric)  dis- 
eases. Contracted  joints  may  be  extended  under  ether  and  then  fixed  by 
splints.     For  Hysteric  Paralysis,  try  metallotherapy. 

Impetigo. — It  is  nearly  allied  to  eczema,  and  eruptions  are  common 
which  are  inter-mediate  between  the  two.  But  impetigo  is  a  pustular,  not 
a  vesicular  disease,  and  forms  thick  crusts  and  scabs.  Causes. — Chronic 
irritation  ;  for  instance,  "grocer's  itch,"  an  impetigo  of  the  hands,  is  caused 
by  constant  contact  with  sugar.  Dirt,  lice,  contagion,  s^-philis.  Situation. 
Usually  head,  hands,  or  face.  Pustules  usually  correspond  to  hau'-follicles. 
Syphilitic  impetigo  occurs  in  large  patches.  Treatment. — Poultifce  to 
fetch  off  scabs.     Ung.  ziaci ;  ung.  hydrarg.  ammon. ;  ung.  sulphuiis,  and 


IMPOTENCE.  141 

mixtures  of  these  ointments.     Treat  general  health,  and  syphilis  if  present. 
Sulphur  baths. 

Impotence. — Incapacity  for  sexual  intercourse.  Note  the  diflference 
between  this  definition  and  that  of  steriHty.  Impotence  occurs  in  wom- 
en as  well  as  men.  Causes. — 1.  Original  maKormation  of  copulatory  or- 
gans ;  marked  epispadias  or  hypospadias  ;  absence  or  occlusion  of  vagina 
and  double  vagina.  2.  Accidental  deformity  of  copulatory  organs ;  am- 
putation of  whole  penis  ;  occlusion  or  obliteration  of  vagina  by  cicatricial 
contraction.  3.  Organic  affections  of  the  less  suj^erficial  genito-urinary 
organs  ;  spermatorrhoea  ;  varicocele  ;  castration.  4.  Nei*vous  influences. 
The  condition  called  "  ii'ritability  with  weakness  "  usually  depends  on  both 
third  and  fourth  class  of  causes.  When  impotence  is  not  the  effect  of 
visible  maKormation,  it  almost  always  is  the  result  of  masturbation,  very 
rarely  of  sexual  excess.  Mastturbation  usually  leads,  in  the  fii'st  place,  to 
"  initability  with  weakness."  Here  ejaculation  takes  place  before  entrance 
is  effected,  or  else  erection  is  impossible,  and,  consequently,  copulation 
imiDOSsible.  This  condition  is  not  always  the  result  of  masturbation. 
Disgust  for  the  female,  or  the  fear  of  sin  or  of  contagious  disorders, 
doubtless  causes  it  in  some  cases.  Signs  and  Prognosis. — Some  are  given 
in  the  preceding  j)aragraphs.  Sometimes  the  genitals  are  flabby,  cold,  and 
small.  If,  in  such  cases,  erections  never  occur,  not  even  in  bed  in  the 
morning,  the  prognosis  is  not  very  good.  But  so  long  as  erections  occur 
at  all,  the  prognosis  is  very  hopeful.  Treatment. — Four  principles :  1, 
strengthen  general  health;  fresh  air,  sleep,  moderation  in  all  things — in 
exercise,  in  diet,  and  in  mental  work  ;  2,  avoid  all  unnatural  excitement  of 
genital  organs  ;  3,  treat  any  physical  defect  which  can  be  found.  If  there 
is  the  slightest  sign  of  varicocele  or  relaxation  of  scrotum,  give  patient  a 
susjDensor}^  bandage ;  4,  to  complete  the  cure — at  all  events,  to  demon- 
strate the  cure  to  the  patient — requires  the  moderate  and  regular  practice 
of  sexual  intercourse  for  a  short  time.  Of  course,  it  is  right  that  this 
should  be  done  in  the  marriage  state.  Paget  WTites  :  "  Some  will  expect 
you  to  prescribe  fornication.  I  w^ould  just  as  soon  prescribe  theft  or 
lying,  or  anything  else  that  God  has  forbidden.  Celibacy  does  no  harm 
to  mind  or  body  ;  its  discipline  is  excellent :  marriage  can  be  safely 
waited  for."  If  the  patient  is  already  married,  attend  to  the  first  three 
indications,  give  some  mysterious  and  hannless  medicine,  and  forbid  in- 
tercovu'se  for  three  weeks.  "The  nonchalance  that  he  thus  acquires 
during  sexual  excitement,  and  inattention  to  the  strength  and  duration  of 
the  erections,  render  cohabitation  possible,  and  he  has  the  first  successful 
coitus  during  the  time  it  was  forbidden."  Lallemand's  porte-caustique. 
A  solution  of  argent,  nit.  (gr.  v.  to  3  j)  is  applied  to  prostatic  part  of  ure- 
thra every  day.  This  is  a  treatment  now  unjustly  neglected.  Faradiza- 
tion of  inner  surface  of  thigh,  of  testicles,  and  lower  part  of  spine.  Con- 
stant current  to  spine.     "Positive  pole  over  fifth  dorsal  vertebra,  negative 


142  INFLAMMATION. 

over  sacrum,  or  pexinasum.  Three  or  four  sittings  a  week,  one  to  three 
minutes  each."     Battery,  20  to  30  Daniel's  elements  of  medium  size.' 

Incontinence  of  Urine. — Diifers  very  much  in  cause  and  treatment, 
according  as  it  occurs  in  children,  hysterical  young  people,  or  in  adults. 
Causes. — 1.  In  children  :  either  wilful  laziness  or  a  genuine  disease,  prob- 
ably partial  anaesthesia  of  bladder.  More  remote  causes  are  worms,  cal- 
culus, and  struma.  2.  In  hysterical  gii'ls :  vide  causes  of  hysteria.  3.  In 
adults :  a  distended  state  of  bladder,  the  result  of  paralysis.  Those  cases 
in  which  the  urine  can  only  be  retained  in  the  bladder  for  a  short  time 
may  be  classed  "with  iBRixABnjTY  of  the  Bladdee,  quod  vide.  Treatment. — 
1.  Of  incontinence  in  children  :  remove  the  cause  ;  treat  the  patient  kindly, 
rather  encourage  than  fiighten  him  ;  avoid  corporal  punishment  in  chil- 
di-en  ;  flannel  clothing  at  night';  wake  the  child  every  three  horu's  to  mic- 
turate' ;  try  cold  douche  to  sjDine  every  morning.  Extractum  belladonna, 
gr.  ^,  or  tinct.  belladonna.  Til,  x.  ter  die.  Tonics  ;  strychnine,  canthar- 
ides,  chloral  at  bed-time.  For  hysterical  incontinence,  treat  the  hysteria. 
Cold  sitz-baths.  For  incontinence  from  paralysis,  see  Bladder,  Paralysis 
OF.  Incontinence  also  arises  fi-om  enlargement  of  middle  lobe  of  prostate. 
See  Prostate,  Hypertrophy  of. 

Inflammation. — Definition. — "When  a  structure  is  attacked  with  in- 
flammation, there  is  active  h^^^ersemia  of  the  j)art  itself,  accumulation  of 
leucocytes  outside  its  blood-vessels,  and  a  disturbance  of  its  nutrition.  In 
the  case  of  a  non-vascular  part,  the  hyper.T?mia  is  in  its  immediate  neigh- 
hood,  9,nd,  perhaps,  the  increase  of  corpuscles  is  due  to  the  division  of  the 
proper  corj)uscles  of  the  part.  So  far  there  is  nothing  in  the  above  defi- 
nition to  distinguish  inflammation  from  the  process  of  repair.  And  there 
can  be  no  doubt  that  the  word  "  inflammation  "  is  constantly  used  to  name 
action  which  is  identical  with  the  j^rocess  of  rejoair,  e.g.,  in  the  case  of 
most  sHght  localized  "inflammations"  terminating  in  what  is  called  "ad- 
hesion." Inflammation  is  usually  defined  from  "repair "by  saying  that 
it  is  "  an  excess  of  action."  This  definition  aj^pears  to  be  scarcely  satisfac- 
tory. "When  the  surgeon  says  that  a  wound  is  inflamed,  in  ninety-nine  cases 
out  of  a  hundred,  if  not  in  the  whole  hundred  cases,  the  state  of  things 
is  probably  this:  Processes  identical  with  those  necessary  to  "repau*" 
have  begrm  around  the  lymph-capillaries  near  the  wound  ;  whereas  the  ac- 
tion ought  to  have  been  confined  to  the  actual  base  and  borders  of  the 
wound  itself.  The  term  inflammation,  as  commonly  used  in  sui-gery,  thus 
does  sometimes  mean  an  excess  of  action,  and  sometimes  means  action 
which  it  would  be  absurd  to  caU  excessive,  as,  for  instance,  in  the  very  lo- 
calized "  inflammation "  which  so  often  prevents  extravasation  of  fneces 
through  a  wound  of  intestine.  In  the  latter  case  the  phenomena  of  "  inflam- 
mation "  cannot  be  shown  to  differ  from  "  repair."  In  the  former  they  differ 

'  See  Dreschfeld,  Practitioner,  vol.  xiii. ,  p.  360. 


INFLAMMATION.  143 

in  this  respect,  namely,  that  the  processes  have  spread  from  the  region 
where  they  might  have  been  useful  to  the  vessels  around  the  neighboring 
lymphatics,  where  they  are  worse  than  useless. 

Caution. — I  do  not  recommend  the  student  under  examination  to  trouble 
himself  about  the  immediately  foregoing  remarks.  He  will  find  most 
safety  in  merely  speaking  of  inflammation  as  a  "  perverted  vital  action  "  or 
"modified  nutrition,"  and  then  plunging  instantly  into  a  description  of  its 
observed  phenomena,  etc. 

Causes. — A.  Predisposing :  1,  plethora,  especially  if  coincident  with  a 
weak  circulation ;  2,  local  congestion ;  3,  impiu-ity  of  the  blood,  such  as 
arises  from  kidney  or  lung  disease ;  4,  alcohoUsm  ;  5,  chronic  inanition 
(?  does  this  cause  inflammation  or  only  modify  it  in  an  evil  manner)  ;  6, 
atheromatous  arteries ;  7,  defective  innervation  ;  8,  bodily  state  left  after 
certain  zymotic  diseases,  e.g.,  measles  and  typhoid;  9,  specific  "diatheses," 
e.g.,  gouty,  strumous,  and  rheumatic ;  10,  congenital  peculiarities.  The 
above  hst  could  be  amplified  ad  infinitum  by  going  into  detail,  e.g..  Cause 
2  includes  all  the  causes  of  oedema  and  drojDsy,  varicose  veins,  pressiu'e  of 
tumors  on  veins,  etc.,  etc.  B.  Exciting  causes  :  1,  physical ;  2,  chemical. 
Both  these  may  be  either  of  external  or  internal  origin,  e.g.,  a  joint  may 
inflame  from  the  physical  u-ritation  of  a  contusion,  or  of  a  loose  cartilage, 
or  from  the  chemical  irritation  of  an  iodine  injection  or  of  gouty  products. 
The  common  practice  of  classing  quite  separately  the  morbid  products  of 
the  body  itself  is  illogical ;  for  these  products  act  either  physically  or 
chemically  ;  3,  injuries  or  diseases  of  nerves  ;  4,  specific  influences.  Phys- 
ical causes  include  blows,  wounds,  strangulation,  etc.  ;  chemical  include 
eflects  of  strong  acids  and  alkahes,  and  of  septic  material.  An  example  of 
inflammation  following  nerveiinjury  is  that  of  the  eyeball  which  follows  in- 
jiuy  of  the  ophthalmic  nerve.  Specific  influences  are  such  as  syphiHs, 
small-pox,  and  measles.  The  action  of  heat  and  cold  are  partly  chemical 
and  partly  physical. 

Phenomena. — Classical  signs :  pain,  heat,  redness,  swelling.  Pain. — 
results  from  either  tension  or  compression  of  nerve-fibrils.  Its  character 
and  intensity  vary  with  the  locality.  Osteitis  causes  aching,  phlegmonous 
erysipelas  causes  throbbing  pain,  and  supei-ficial  inflammations  produce 
burning,  tingling  pains.  With  pain  is  associated  tenderness.  In  the 
nerves  of  special  sense,  special  sensations  take  the  place  of  pain,  e.g.,  tin- 
nitus aurium  in  catarrh  of  the  tymjDanum,  while  the  intolerance  of  light  in 
ophthalmia  is  analogous  to  tenderness.  Pain  is  often  diffused,  e.g.,  pain 
throughout  one  side  of  face  and  head  in  toothache  ;  or  reflected,  e.g.,  pain 
in  knee  from  hip  disease.  Heat. — Inflamed  parts,  except  in  very  chronic 
cases,  feel  sensibly  hotter  than  normal.  According  to  Mr.  Simon  and  Dr. 
Montgomery,  the  blood  leaves  the  inflamed  part  hotter  than  it  enters  it, 
and  the  inflamed  part  is  hotter  than  either  the  blood  which  flows  into  it  or 
the  blood  which  flows  out  of  it.     Continental  observations  on  this  question 


144  INFLAMMATION. 

have  been  numerous  and  conflicting.  The  subject  of  rise  of  general  bodily 
temperature  is  noticed  under  the  head  of  Fever.  Redness. — Due  to  hyper- 
{jemia.  Bright  when  there  is  active  fluxion  of  blood  to  the  capillaries  of 
the  part,  as  is  usual  in  acute  inflammations  ;  dull,  perhaps  blue  or  brown- 
ish red,  when  the  congestion  is  more  passive,  as  is  usual  in  chronic  inflam- 
mations. When  a  non-vascular  part  inflames,  the  redness  is  observed  in 
the  neighboring  vascular  region  fi'om  which  the  inflamed  part  derives  its 
nutrition.  Swelling. — Partly  due  to  congestion,  partly  to  effusion.  Effu- 
sion resembles  in  character  liquor  sanguinis,  but  it  contains  excess  of 
chloride  of  sodium  and  of  phosphates.  It  also  contains  leucocytes  and 
even  red  blood-corpuscles.  As  a  consequence  of  excess  of  chloride  of 
sodium  in  the  effusion,  there  is  a  deficiency  of  that  salt  in  the  urine.  The 
characters  of  the  effusion  differ  in  different  inflammations  ;  especially  vari- 
able is  the  amount  of  fibrine. 

Pathology. — Microscopic  obser^-ation  of  an  inflamed  part,  e.g.,  the  web 
of  a  frog's  foot  which  has  been  exposed  to  irritation,  shows  aj)pearances 
which  may  be  described  under  three  heads,  viz.  :  1,  disorder  of  circulation  ; 
2,  exudation  ;  3,  stasis.  After  describing  these,  I  shall  consider  the  struc- 
tural changes  which  take  place  in  the  constituents  of  the  inflamed  part. 
1.  Disorder  of  Circulation. — Dilatation  of  the  arteries  is  the  first  phenom- 
enon observed  in  an  inflamed  region.  It  is  ordinarily  preceded  by  no  an- 
tecedent contraction.  It  increases  gradually  for  ten  or  twelve  hours,  and 
remains  at  its  maximum  for  many  hours.  Dilatation  of  the  veins  follows 
at  a  long  interval  of  time.  The  rate  of  circulation  at  the  commencement 
is  increased,  but  this  soon  changes  to  the  very  reverse,  viz.,  abnormal  slow- 
ness. The  cause  of  the  vascular  dilatation  is  undetermined,  but  a  very  rea- 
sonable hypothesis  attributes  it  to  inhibitory  nervous  influence.  Billroth 
thus  states  this  view :  "  We  actually  know  such  phenomena  fi'om  phys- 
iology ;  the  obstruction  of  the  heart's  action  by  ii'ritation  of  the  vagus 
nerve,  of  the  movements  of  the  intestines  from  irritation  of  the  splanchnic 
nerves,  etc.  Here  a  vaso-motor  nerve-system  is  supposed  which  arrests  the 
contraction  of  the  muscles ;  could  not  such  a  vaso-motor  nerve-system  also 
be  supposed  for  the  vessels — nerves,  irritation  of  which  lessens  the  tone  of 
the  muscles  of  the  vessels  and  thus  renders  the  walls  less  capable  of  resist- 
ing tlie  pressirre  of  blood  ?  "  That  local  nerves  have  an  unquestionable  in- 
fluence over  the  circulation  in  inflamed  parts  has  been  experimentally 
proved  {see  Holmes's  "System,"  vol.  v.,  pp.  735-6-7-8).  Ammonia  when 
used  as  an  irritant  to  excite  inflammation  has  this  exceptional  property—  it 
excites  a  prehminary  arterial  contraction  before  the  ordinaiy  vascular  dilata- 
tion. 2.  Exudation. — As  soon  as  the  rate  of  circiilation  begins  to  slacken, 
white  blood-corpuscles  or  leucocytes  begin  to  accumulate  and  loiter  along 
the  side  of  the  minute  veins  and  capillaries.  "  In  this  way  the  vein  be- 
comes lined  with  a  continuous  pavement  of  these  bodies,  which  remain  al- 
most motionless,  notwithstanding  that  the  axial  current  sweeps  by  them 


INFLAMMATION.  145 

as  continuously  as  before,  though  with  abated  velocity.  Now  is  the  mo- 
ment at  which  the  eye  must  be  fixed  on  the  outer  contour  of  the  yessel, 
fi'om  which  (to  c[uote  Professor  Cohnheim's  words),  here  and  there,  minute, 
colorless,  button-shaped  elevations  spring,  just  as  if  they  were  produced  by 
budding  out  of  the  wall  of  the  vessel  itself.  The  buds  increase  gradually 
and  slowly  in  size,  until  each  assumes  the  form  of  a  hemispherical  projec- 
tion, of  width  corresponding  to  that  of  a  leucocyte.  Eventually  the  hemi- 
S23here  is  converted  into  a  pear-shaped  body,  the  stalk  end  of  which  is  still 
attached  to  the  surface  of  the  vein,  while  the  rotmd  part  projects  freely. 
Gradually  the  little  mass  of  protojolasm  removes  itself  farther  and  farther 
away,  and,  as  it  does  so,  begins  to  shoot  out  delicate  prongs  of  transparent 
protoplasm  from  its  surface,  in  no  wise  differing  in  their  aspect  from  the 
slender  thread  hj  which  it  is  stiU  moored  to  the  vessel.  Finally,  the  thread 
is  severed  and  the  process  is  complete.  The  observer  has  before  him  an 
emigrant  leucocyte"  (Burdon-Sanderson).  But  although  all  the  leucocytes 
observed  outside  the  vessels  in  the  earlier  stages  of  inflammation  have  prob- 
ably escaped  from  the  vessels,  there  is  stiU  reason  to  believe  that  later  ac- 
cumulations of  them  are  partially  due  to  jjroHferation  of  the  extra-vascular 
corpuscles.  3.  Stasis. — The  phenomena  of  stasis  occur  at  an  uncertain 
time  dui'ing  the  course  of  inflammation,  but  they  are  not,  as  is  sometimes 
stated,  the  first  in  order  of  occurrence.  They  are  twofold ;  firstly,  the 
blood- current  stops  altogether,  after  getting  gradually  slower  and  then  os- 
cillating ;  secondly,  the  colored  corpuscles  cohere  to  one  another,  and  ad- 
here to  the  sides  of  the  vessels  till  they  form  an  accumulation  so  dense 
that  the  capillaries  seem  to  contain  no  Hquor  sanguinis,  but  only  corpuscles. 
As  similar  occurrences  take  place  even  when  milk  is  substituted  for  blood, 
and  as  the  blood  drawn  in  inflammation  shows  no  sj)ecial  arrangement  of 
its  corpuscles,  it  is  assumed  that  the  phenomena  of  stasis  are  due  to  a 
changed  condition  of  the  walls  of  the  blood-vessels.* 

Structural  Changes  which  Take  Place  in  Constituents  of  Inflamed  Tissues. 
— In  non-vascular  tissue,  such  as  that  of  the  cornea  and  of  caa'tilage, 
the  proper  cornea  and  cartilage  corpuscles  proliferate.  But  numbers  of 
leucocytes  migrate  from  the  vessels  around  the  cornea  into  its  substance. 
In  cartilage  the  cartilage-cells  multiply  by  division,  and  then  cause  the 
absorption  of  the  stroma  in  which  they  lie.  In  tendon  and  in  muscle  sim- 
ilar changes  have  been  observed.  Li  the  case  of  paii;s  lined  with  epithe- 
lium, such  as  mucous  and  serous  membranes  and  glands,  it  is  probable 
that  the  greater  part  of  the  corpuscles  of  the  inflammatoiy  new  formation 


'  If  the  vascular  walls  permit  much  of  the  liquor  sanguinis  to  leak  through  them, 
the  speed  of  that  which  remains  in  the  vessel  will  be  sldwed.  It  is  easy  to  see  how  re- 
tardation of  the  current  of  liquor  sanguinis  would  allow  leucocytes  to  accumulate,  be- 
cause of  the  absence  of  the  normal  force  which  ordinarily  washes  them  along  the 
blood-vessels.— See  St.  Bartholomew's  Hospital  Reports,  1878,  p.  299. 
10 


146  INFLAMMATION. 

are  escaped  leucocytes  ;  but,  at  least  in  the  case  of  epithelial  membranes, 
proliferation  of  epithelium  appears  to  have  been  observed. 

Fiu-ther  changes  ai-e  described  under  headings  noticed  in  the  following 
paragTaph. 

Terminations  vf  Injlammation. — 1,  Resolution  ;  2,  adhesion  or  organiza- 
tion ;  3,  suppui-ation,  including  abscess ;  4,  ulceration ;  5,  gangrene  or 
mortification.  These  processes  are  described  respectively  under  the  fol- 
lowing heads  :  1,  2,  and  3,  Wounds,  Eepaik  of  ;  3,  Abscess  ;  4,  Ulceration  ; 
5,  Gangrene. 

Treatment  of  Inflammation. — Consider  it  under  heads — A,  indications  ; 
B,  remedial  agents  ;  C,  differences  according  to  whether  a  case  is  acute  or 
chronic.  A.  Indications :  1,  to  remove  all  sources  of  ii'ritation  and  all 
predisj)osing  causes ;  2,  to  lessen  local  action  ;  3,  to  guai'd  against  or  treat 
promptly  all  compHcations,  or  evil  consequences  ;  4,  to  support  the  pa- 
tient's strength  during  prolonged  and  exhausting  cases  ;  5,  to  relieve  pain. 
B.  Remedial  agents.  These  ai-e  either  local  or  general.  Local  agents — 
rest,  cold,  bloodletting,  pressvu'e,  ligature  or  compression  of  artery  sup- 
plying inflamed  part,  incisions,  antisepsis,  warmth  with  moisture,  astrin- 
gent and  stimulating  drugs,  counter-irritation  ;  and  certain  other  agents 
which  will  be  noticed  in  considering  the  treatment  of  chronic  inflamma- 
tion. Constitutional  agents  are :  rest,  bloodletting,  dieting,  stimulation, 
di-ugs,  mercury,  antimony,  aconite,  belladonna,  pvu'gatives,  diui-etics,  colchi- 
cum,  iodide  of  potassium,  quinine,  oj)ium,  other  anodynes  ;  diaphoresis  ; 
"  spinal "  ice-bags.  Some  of  the  agents  in  the  above  Hst  overlap  one 
another,  e.g.,  "  diaphoresis"  partly  includes  "  antimony ;"  but  it  is  impos- 
sible to  devise  a  satisfactory  list  without  this  fault. 

Hest. — Bed,  splints,  slings,  cradles,  bandages  (starch,  plaster-of -Paris, 
paraffin,  glue,  gum,  silicate  of  potash).  Position  :  elevation.  Flexion  or 
extension.  See  Joint  Diseases  and  Fractures.  Cold. — Ice-bags,  bags 
through  which  a  continuous  stream  of  cold  water  can  be  made  to  pass, 
irrigation,  cold  douche,  wet-packing,  evaporating  lotions.  Excessive  cold 
with  wet  involves  danger  of  fi-ost-bite.  Local  Bloodletting/.- — Leeches,  cup- 
ping, dry  cupping,'  incisions,  scarifications,  punctures,  local  venesection 
{i.e.,  pricking  veins  near  inflamed  part).  Pressure. — Bandages  with  sub- 
jacent layer  of  cotton-wool ;  elastic  bandage,  pressure  regulated  by  means 
of  india-rubber  bags  containing  water,  ^  shot  bags.  Ligature,  compression 
or  acupressure  of  artery  of  inflamed  part  or  main  artery  of  limb.  Neudorfer 
says  eight  minutes  of  pressure,  three  or  four  times  a  day,  suffice.  In- 
cisions.— Though  mentioned  above  in  connection  with  local  bloodletting, 
are  yet  more  frequently  used  to  relieve  tension.  Extent  and  depth  vary  ; 
usually  they  are  about  l^.in.  long  by  ^  in.  deep.   Avoid  vessels  and  nei-ves 

'  Of  course  the  dry-cupping  is  not  really  bloodletting,  but  its  action  is  similar. 
^  See  Lancet,  November,  1878. 


INFLAMMATION.  147 

of  any  size.  Cut  in  axis  of  limb.  Antisepsis. — See  Antiseptic  Treatment 
and  Wounds.  WarTnth  with  Moisture. — Poultices,  fomentations,  water-dress- 
ing, spongiopiliue.  Astringent  and  Stimulating  Drugs. — Extract  of  bella- 
donna and  glycerine,  equal  parts  ;  silver  nitrate,  tannic  acid,  and  all  tlie 
various  astringent,  stimulant,  caustic,  and  sedative  drugs  used  in  cutaneous 
and  throat  medicine.  Counter-invitation. — Vesicants,  caustics,  cautery, 
moxa,  issues,  setons,  friction,  shampooing,  poultices. 

Constitutional  Agents. — General  Bloodletting.  Indications  for  :  Severe 
inflammations  of  the  contents  of  the  head  or  thorax,  following  compara- 
tively slight  injui-ies  and  attended  with  a  frequent,  full,  and  hard  j)ulse. 
The  bleeding  should  be  full  and  free  fi-om  a  large  vein  (e.g.,  median-ba- 
silic), but  not  pushed  to  fainting.  Repeat  if  necessary,  and  if  immediate 
result  of  bleeding  be  encouraging.  Amount,  usually  about  10  ounces. 
Diet. — Abstinence  from  food.  Low  diet.  Former  may  be  j)rescribed  for 
a  day  or  two  in  some  cases  of  abdominal  injury  and  inflammation.  Low 
diet  almost  always  beneficial.  Stimulation. — Full  diet ;  extra  nouiishment. 
For  cases  of  low  type,  when  the  general  weakness  seems  more  threaten- 
ing than  the  local  inflammation.  Drugs. — Mercury,  antimony,  aconite, 
belladonna,  purgatives,  diuretics,  colchicum,  iodide  of  potassium,  quinine, 
opium,  other  anodynes.  See  some  book  on  Therapeutics,  and  the  notices 
of  inflammations  of  special  parts  or  of  specific  origin  in  this  book.  Aconite 
very  valuable.  DiajDhoresis. — Effected  either  by  drugs  (antimony,  Dover's 
powder),  or  by  hot-air  baths,  blankets,  or  other  j)hysical  agents.  Spinal 
Ice-bag,  Spinal  Hot- water  Bag. — -According  to  Dr.  Chapman,  former,  by  j^ar- 
tially  paralyzing  vaso-motor  system,  increases  the  flow  of  blood  to  that 
part  of  the  body  which  corresj)onds  to  the  region  of  the  spine  to  which  the 
ice-bag  is  apx^lied,  e.g.,  pelvic  organs  become  actively  congested  and  feet 
warm  when  ice-bag  is  a^jplied  to  lower  part  of  spine.  On  the  other  hand, 
the  hot-water  spinal  bag  has  an  action  the  very  reverse  of  this  ;  hence  the 
ice-bag  can  be  used  to  obtain  a  derivative  action,  and  the  hot- water  bag  to 
directly  contract  the  arterioles  of  an  inflamed  part. 

C.  Differences  in  Treatment,  according  to  ivhether  the  Inflammation  is 
Acute  or  Chronic. — Li  acute  cases  the  indications  ai'e  usually  to  save  life, 
to  check  the  attack  before  serious  local  mischief  has  been  effected,  to  pre- 
vent the  spread  of  a  localized  inflammation,  and  to  relieve  pain.  In  treat- 
ing chronic  cases  the  surgeon  has  rather  to  attempt  the  removal  of  what 
may  be  termed  pathological  habits,  and  their  evil  effects.  In  acute  cases 
he  employs  such  active  agents  as  venesection,  free  leeching,  and  the  ad- 
ministration of  drugs  which  powerfully  affect  the  nervous  and  vascular 
systems  {e.g.,  opium  and  aconite).  In  chronic  cases  resort  is  had  to  pres- 
sure, friction,  counter-ii-ritation,  and  stimulant  or  astringent  di-ugs  locally 
{e.g.,  silver  nitrate),  with  "alteratives"  internally  {e.g.,  mercury,  iodide  of 
potassium,  sarsaparilla).  It  is  especially  in  many  chronic  cases  that  a 
tonic  and  generous  plan  of  treatment  has  to  be  adopted.     In  dealing  with 


148  INTESTINAL    OBSTEUCTION. 

clironic  inflammations  always  seek  for  some  long-acting  cause,  or  for  some 
specific  influence  {e.g.,  syphilis,  struma,  rheumatism). 

Insects,  Stings  of. — See  Bees,  Stings  of. 

Intestinal  Obstruction. — Causes. — 1,  Intussusception  ;  2,  strangula- 
tion by  bands  or  by  congenital  diverticula  ;  3,  volvulus  or  twisting  ;  4,  in- 
ternal hemise ;  5,  strictures — malignant,  cicatricial,  or  simple  ;  6,  pressure 
of  tumors  or  dragging  of  the  bowel  out  of  place  ;  7,  impaction  of  faeces  or 
of  foreign  bodies ;  8,  pouching  of  intestine  ;  9,  intestinal  paralysis.  Ac- 
cording to  PoUock,  of  135.  cases  24  arose  from  intussusception,  3G  from 
bands,  diverticula,  and  the  like,  33  from  intrinsic  stricture,  8  from  internal 
hernia,  7  from  concretions,  calculi,  and  foreign  bodies,  4  from  volvulus  of 
sigmoid  flexure,  3  from  fecal  accumulations,  9  fi'om  peritoneal  adhesions, 
tubercle,  etc.,  and  8  were  doubtful.  Pathology. — 1.  Intussusception.  Por- 
tion of  intestine,  usually  lower  end  of  ileum,  becomes  invaginated  in  the 
portion  immediately  below  it.  If  the  case  proceeds,  the  fai'ther  invagination 
takes  2:)lace  chiefly  at  the  expense  of  the  lower,  that  is,  the  containing  j)art 
of  the  bowel ;  e.g.,  an  intussusception  commencing  at  the  lower  part  of  the 
small  intestine  will  gradually  absorb  caecum,  ascending  colon,  etc.,  till  the 
cfficum  appear  even  out  of  the  anus.  Of  course  a  section  of  an  intussus- 
ception would  show  three  concentric  cylinders,  of  which  the  inmost  and 
middle  present  serous  surfaces  toward  each  other,  while  the  middle  and 
outmost  touch  each  other  on  their  mucous  surfaces.  Between  the  inmost 
and  middle  cylinders  is  the  mesentery,  tapering  to  a  point  at  the  lower 
end  of  the  involution  and  causing  an  arching  of  the  involuted  jjart  of  the 
intestine  toward  its  mesenteric  border.  The  orifice  at  the  lower  end  of 
the  central  cyHnder,  namely  that  which  opens  into  the  bowel  below  the 
disease,  is  a  slit  and  not  cu'cular.  Peritonitis  and  adhesions  usually  occur, 
though  often  not  till  very  late  in  the  course  of  the  case.  Enteritis  occurs 
and  causes  mucous  and  bloody  stools.  The  natural  process  of  cure  is  for 
the  involuted  intestine  to  inflame,  become  strangulated,  slough,  and  come 
away  per  anum.  2.  Strangulation  by  hands  or  by  congenital  diverticula. 
Bands  are  usually  adhesions  of  inflammatory  origin  ;  they  are  often  at- 
tached to  diverticula.  Diverticula  are  mostly  found  at  the  lower  end  of 
the  ileum.  They  originate  either  from  a  partial  persistence  of  the  omphalo- 
mesenteric duct  or  from  a  hernia  of  the  mucous  coat  of  the  bowel.  3. 
Volvulus.  Three  varieties  ;  1st,  when  bowel  is  rotated  on  its  own  axis,  only 
occiu's  in  ascending  colon  ;  2d,  when  mesentery  forms  the  axis  and  is 
twisted  into  a  cone,  only  occurs  in  small  intestine  ;  3d,  when  one  cod  of 
intestine  forms  the  axis  round  which  another  coil  is  bent.  Most  volvuli 
occur  in  sigmoid  flexure.  Loose  flabby  mesentery  usually  found  in  these 
cases.  4.  Internal  hernice.  See  Hernia.  5.  Strictures.  Almost  all  occm- 
in  large  intestine.  Causes  :  citjatrices  of  tuberculous  or  of  dysenteric  ul- 
cers, or  of  ulcers  caused  by  irritation  of  foreign  bodies  ;  inflammatoiy  effu- 
sion and  contraction  in  the  substance  of  the  intestinal  wall ;  cancer.     The 


INTESTINAL    OBSTRUCTION.  149 

last  cause  is  the  most  common.  The  pathology  of  the  remaining  causes 
of  intestinal  obstruction  need  not  be  considered  in  detail  here. 

Signs. — Vomiting,  constipation,  abdominal  pain  ;  constitutional  depres- 
sion ;  there  are  modified  and  s^iecial  symptoms  added  according  to  jDi-ime 
cause. 

Diagnosis. — 1st,  from  other  diseases  causing  vomiting,  constipation, 
and  pain  ;  2d,  of  the  particular  nature  of  a  given  case  of  obstruction.  1st, 
bear  in  mind  possibility  that  the  symptoms  are  caused  by  peritonitis,  peri- 
tyj)hlitis,  passage  of  a  gall-stone,  impaction  of  a  calculus  in  the  ureter. 
Abstract  of  Mr.  J.  Hutchinson's  memoranda  for  diagnosis :  1.  If  patient 
be  a  child,  and  the  onset  of  symptoms  be  sudden — ^probably  intussuscej)- 
tion  or  peritonitis.  2.  If  an  elderly  person — impaction  of  fseces,  or  else 
malignant  disease  (strictiu-e  or  tumor).  3.  Middle  age — intussusception 
and  malignant  disease  very  unusual.  4.  Intussusception  causes  fi-equent 
straining,  passage  of  blood  and  mucus,  incompleteness  of  constipation, 
discovery  of  a  sausage-like  tumor,  either  per  anum  or  through  abdominal 
■walls.  5.  Also  in  intussusception,  parietes  usually  lax,  and  therefore  it  is 
almost  always  possible  to  feel  the  sausage-hke  tumor  by  manipulation  un- 
der ether.  6.  Mahgnant  stricture.  Old  person,  continued  abdominal 
uneasiness,  repeated  attacks  of  temporary  constipation.  Constipation 
often  not  complete.  7.  Tumor  should  be  discoverable  either  through 
parietes  or  else  per  aninn  or  |jer  vaginam.  Beware  of  confounding  with 
scybalous  masses.  (Latter  may  probably  be  indented  or  pressed  into  a 
different  shape.)  8.  If  there  have  been  repeated  attacks  of  dangerous 
obstruction  with  long  intervals  of  perfect  health,  suspect  diverticula,  or 
bands,  or  pouching  with  liabiHty  to  twist  (volvulus).  9.  Abdomen  hard 
and  distended  from  near  commencement  of  case,  peiitonitis  almost  cer- 
tainly. 10.  Intestines  ^isibly  rolling  about.  Almost  certainly  no  perito- 
nitis. 11.  The  tendency  to  vomit  is  in  propoi-tion  to  (1)  nearness  of  im- 
pediment to  stomach,  (2)  tightness  of  consti'iction,  (3)  persistence  with 
which  food  and  medicine  have  been  given  by  the  mouth.  12.  Vomiting 
often  absent  in  cases  of  obstruction  in  the  colon  or  rectum.  13.  Violent 
retching  and  bile-vomiting  often  more  troublesome  in  cases  of  gall-stones 
or  renal  calculus  simulating  obstruction  than  in  true  conditions  of  the 
latter.  14,  Fecal  vomiting  can  occur  only  when  the  obstruction  is  mod- 
erately low  down.  WTien  happening  early  in  the  case,  it  is  very  serious,  as 
it  implies  tightness  of  constriction.  15.  Hand  in  rectum  may  obtain  useful 
information. 

Treatment.— 'Fir&i  question  is  that  of  gastrotomy.  Indications  for  gas- 
tromy  are  a  tolerably  clear  diagnosis  of  intussusception,  strangulation  by 
band,  volvulus,  or  internal  hernia.  Of  course  in  many  of  these  cases 
other  means  should  have  been  fairly  tried  before  resorting  to  abdominal 
section.  It  is  to  be  remembered  on  the  one  hand  that  most  operations  of 
the  kind  have  been  fatal,  while  many  cases  presenting  bad  symptoms  have 


150  ISCHIO- RECTAL    ABSCESS. 

recovered  spontaneously  ;  on  the  other  hand  there  are  cases  in  which  hope 
of  spontaneous  recovery  is  out  of  the  question.  Antiseptic  precautions 
will  diminish  the  risk.  In  cases  of  incurable  stricture,  an  artificial  anus 
iTiust  be  formed.  Vide  Colotomy.  When  exact  seat  of  disease  is  doubt- 
ful, operate  in  right  loin.  If  upper  part  of  large  intestine  be  found 
empty,  bring  a  coil  of  small  intestine  into  wound.  In  certain  cases  of 
insuperable  obstruction,  in  which  the  seat  of  disease  is  believed  to  be 
above  the  ctecum,  small  intestine  may  be  opened  through  anterior  abdom- 
inal wall.  Measures  not  Involving  Cutting  Operations. — In  all  early  stages 
and  in  aU  acute  cases  abstain  entirely  from  giving  either  food  or  medicine 
by  the  mouth.  Make  a  careful  examination  under  ether  administered 
fully.  Copious  fluid  euemata.  Insufflation  of  air.  Latter,  though  good 
in  intussusception,  not  to  be  used  where  stricture  is  suspected.  For 
severe  pain,  give  opium  or  morj)hia  with  belladonna.  Employ  abdominal 
taxis,  that  is  aneesthetize  the  patient,  invert  him,  shake  him,  forcibly  knead 
al)domen,  give  enemata  in  inverted  position,  prescribe  prone  position  with 
pelvis  elevated. '  Operation  should  be  done  antiseptically.  Seat  of  pain 
may  indicate  seat  of  obstruction.  Bands  are  usually  found  in  umbilical 
region.  WTien  the  intestines  ai'e  allowed  to  escajDe  freely,  considerable 
difficulty  in  returning  them  is  likely  to  occur.  Still  it  is  sometimes  neces- 
sary to  allow  it  to  a  certain  extent.  Puncture  is  justifiable,  to  facilitate 
their  retui-n  in  cases  of  difficulty. 

Intussusception. — See  preceding  notice  of  Intestinal  Obstkuction. 

Irrigation. — Practice  of  passing  a  continuous  stream  of  water,  usually 
cold,  over  a  wound.  Various  apparatus.  "VVide-necked  bottle,  with  skein 
of  worsted  or  strip  of  hnt  acting  like  a  capillary  syphon.  Tins  and  india- 
rubber  tubes.  The  bend  where  the  india-rubber  tubing  passes  over  edge 
of  vessel  may  be  prevented  from  closing  tubing  up  by  lashing  the  curve  in 
the  tubing  to  a  metal  skewer  bent  into  a  gentle  curve.  Water  may  be 
medicated.  Object  of  iiTigation  is  to  remove  injmious  discharges  as  fast 
as  they  are  formed,  and  to  keep  down  inflammation  by  action  of  cold. 

Ischio-rectal  Abscess. — Acute  or  chronic.  Former  usually  occurs 
in  strong  constitutions,  latter  in  weakly  persons.  Symptoms. — Signs  com- 
mon to  abscess  everywhere.  Chronic  cases  tend  to  spread  nearly  around 
rectum,  and  to  form  sinuses  which  may  on  the  one  hand  burrow  into 
buttock,  and  on  the  other  become  "fistulse  in  ano."  Causes. — Blows, 
kicks,  falls,  anal  fissiu-es,  ulcerations,  impaction  of  foreign  body  in  rectum, 

'  Judging  from  the  appearances  in  a  case  in  which  gastrotomy  was  performed  for 
intussusception,  I  think  that  before  going  through  the  above  proceedings,  it  would  be 
good,  if  the  intussuscepted  bowel  had  descended  as  low  as  the  rectum,  to  attempt  to 
steadily  compress  the  lower  end  of  the  intussusception  for  some  time  ;  because  in  the 
above-mentioned  case  the  difficulty  in  the  evolution  of  the  intussusception  was 
mainly  caused  by  the  swollen  and  congested  state  of  its  lower  end.  (Compare  with 
Mr.  F.  Jordan's  mode  of  reducing  paraphimosis.) 


JAWS,    DISEASES    OF.  151 

phthisical  constitution.  Treatment. — Acute  abscess  requii'es  poultices, 
fomentations,  and  ordinary  treatment.  Chronic  abscesses  should  also  be 
opened  early  by  free  incision,  or  great  danger  of  fistula  will  be  incurred. 
Treat  general  health. 

Jaws,  Diseases  of  [Partly  noticed  imder  heading,  Antktjm,  Diseases 
or]. 

Jaws,  Clostjee  of. — Causes. — 1  (very  rare),  ankylosis  of  tempero-maxil- 
laxj  articulation  ;  2  (usual),  cicatricial  contraction  after  bums,  scalds, 
cancrum  oris,  etc.  Treatment. — In  very  slight  cases  the  mouth  may  be 
forced  open,  and  cicatrix  stretched  by  screw  appliances.  But  in  most  cases 
the  only  hope  of  relief  Hes  in  osteotomy.  Two  methods  of  osteotomy,  one 
from  within  mouth  (Eizzoli's),  the  other  fi'om  without  (Esmarch's).  In  the 
latter,  which  is  preferred,  a  wedge-shaped  piece  of  bone  is  cut  out  of  lower 
jaw  anterior  to  cicatrix.  Operation  for  temporo-maxiUaiy  ankylosis  con- 
sists in  operating  within  the  mouth,  and  cutting  piece  of  bone  out  of 
ramus  of  jaw. 

Jaws,  Necrosis  of. — Causes. — Blows,  exanthemata,  syphilis,  salivation 
by  mercuiy,  chronic  irritation  of  carious  teeth,  fumes  of  phosphorus. 
Cause  sometimes  obscm-e.  Signs.  — Firstly,  those  of  ostitis,  pain  like  tooth- 
ache, swelHng,  etc.;  then  suppvu-ation,  formation  of  sinuses,  detection  of 
exposed  bone,  offensive  discharge.  Effect  on  general  health  usually  greater 
than  necrosis  elsewhere.  Pathology.  — That  of  other  necroses.  Phosphorus 
necrosis  is  said  to  attack  only  where  there  are  carious  teeth  ;  but  Langen- 
beck  denies  this.  Formation  of  new  bone  usually  redundant ;  but  it  tends 
to  waste  when  the  sequestrum  is  removed.  A  sinus  ojDening  externally  near 
jaw  sometimes  merely  signifies  a  carious  tooth.  Treatment. — Treat  the 
cause.  Remove  sequestrum  when  it  has  fairly  loosened,  but  not  before. 
Avoid  cutting  skin  if  possible  ;  if  unavoidable,  make  incisions  below  edge 
of  jaw,  and,  in  males,  where  whiskers  may  cover  scar.  Whole  jaw  has  been 
removed  piecemeal  through  mouth.  Gargles  and  lotions  of  Condy's  Fluid, 
borax,  salicylic  acid.  In  severe  cases  rest  may  have  to  be  secm-ed  by  band- 
ages and  gutta-percha  or  other  splints.  Tonics,  soft  nutritious  food,  fresh 
air.  Fit  artificial  teeth  to  new  jaw.  Specific  remedies  where  indicated. 
Lower  jaw  affected  oftener  than  upper.  Amorphous  phosphorus  does  not 
give  off  the  injurious  fumes. 

Jaws,  Tumors  of,  may  be  cystic,  fibro  cystic,  fibrous,  sarcomatous,  car- 
cinomatous, cartilaginous,  fibro-cartilaginous,  or  osseous.  A  fibrous  or 
sarcomatous  tumor  connected  with  the  periosteum  of  the  alveoli  is  called 
an  "epulis."  This  has  been  noticed  under  that  heading.  Cystic  tumors 
are  the  most  common,  and  are  noticed  among  the  diseases  of  the  Antrum, 
qnod  vide.  Cartilaginous  tumors  are  rare,  but  may  be  very  large.  Ex- 
ostoses on  the  jaw  are  often  of  the  ivory  variety.  Diagnosis. — See  article  on 
Tumors  in  general.  The  chief  point  is  to  recognize  innocency  or  malig- 
nancy.    Mahgnant  growths  increase  rapidly,  are  usually  softish,  infiltrate 


152  JAWS,    DISEASES    OF. 

neighboring  parts,  affect  glands,  arew  painful,  and  sooner  or  later  tend  to 
f ungate.  Treatment. — Open  simple  cysts  by  a  very  free  incision,  stuff 
with  lint,  and  allow  to  granulate  up.  Other  tumors  must  be  removed 
thoroughly  with  knife,  small  saw,  and  cutting  pliers.  Bad  cases  may  re- 
quii'e  removal  of  part  or  even  whole  of  jaw  itself.     See  Excision  of  Jaw. 

Excision  op  Lower  Jaw. — Partial  or  complete.  Done  for  tumor  of  the 
bone.  Incision.  — Depends  on  extent  of  bone  to  be  removed.  Considerable 
portions  can  be  taken  away  through  an  incision  entirely  within  the  mouth. 
Larger  portions  require  an  incision  along  the  lower  margin  of  the  jaw  and 
chin.  This,  if  necessary,  may  be  extended  upward  in  the  median  line  to- 
ward the  lip  ;  but  only  tumors  of  rare  magnitude  justify  division  of  the  lip . 
itself.  A  tumor  which  reached  fi'om  two  inches  above  the  zygoma  nearly 
down  to  the  clavicle  requii-ed  a  curved  incision  from  the  front  of  the  ear 
to  and  through  the  lower  lip.  Many  tumors  may  be  almost  entirely 
separated  from  then*  connections  before  even  the  facial  artery  need  be 
divided.  Li  the  large  tumor  above  referred  to,  this  artery  was  cut  by  the 
last  touch  of  the  knife,  and  tied  almost  before  it  sj)urted.  All  bleeding 
vessels  should  be  secured  without  delay,  as  fi*ee  hemorrhage  is  pecuHaiiy 
embarrassing  in  operations  about  the  mouth.  In  the  smaller  tumors,  a 
tooth  is  extracted  on  each  side  of  the  growth,  and  the  jaw  partially  sawn 
through  and  partially  divided  by  cutting  forceps.  When  the  symphysis 
has  to  be  removed,  the  tongue  must  be  perforated  and  held,  forward  by  a 
piece  of  whipcord,  lest  it  fall  back  and  close  the  glottis.  This  whipcord 
may  be  removed  after  twenty-fom-  hours.  When  the  ramus  is  encroached 
upon,  disarticulation  is  necessary.  Then  keep  the  edge  of  the  knife  close 
to  the  bone,  lest  the  internal  maxillary  artery  be  divided.  Strong  forceps 
may  be  useful.  Depress  the  bone  well,  and  open  the  joint  from  the  front. 
Do  not  divide  or  remove  any  more  mucous  membrane  than  can  be  helped. 
It  is  worth  remembering  that,  in  case  of  dangerous  hemorrhage  after  an 
extensive  operation  of  this  kind,  the  external  carotid,  or  even  the  bifurca- 
tion of  the  common  carotid,  can  easily  be  compressed  between  the  finger 
in  the  pharynx  and  the  thumb  on  the  skin  of  the  neck.  Anaesthesia  should 
be  effected  through  Trendelenburg's  trachea-tampon  and  tube  or  Mill's 
appai-atus. 

Excision  of  Upper  Jaw. — Complete  or  partial.  Performed  for  tu- 
mor of  the  bone.  Comj^lete  excision.  Incise  skin,  etc.,  down  to  bone 
along  a  line  through  middle  of  upper  lip,  round  ala  of  nose,  up  to  near 
inner  canthus  of  eye,  and  lastly  along  lower  margin  of  orbit.  Very  large 
growths  may  require  also  a  cut  through  cheek  from  angle  of  mouth  to 
malar  bone.  Tm*n  this  flap  out  and  divide  bone  in  the  following  places,  in 
whatever  order  may  be  found  most  convenient  in  each  individual  case,  but 
preferentially  as  follows  :  (1)  zygoma,  (2)  outer  wall  of  orbit  into  spheno- 
maxillary fissure,  (3)  inner  angle  of  orbit,  (4)  hard  palate  and  alveolar  pro- 
cess, through  socket  of  central  incisor  tooth,  previously  extracted.     Effect 


JOINTS,    DISEASES    OF.  153 

eacli  division  with  cutting  forceps  ;  but  commence  each,  excejjt  the  third, 
with  a  narrow  saw.  Now  apply  lion  forceps,  depress  the  bone,  separate 
remaining  adhesions  with  fingers  rather  than  with  knife,  and  wrench  out. 
Avoid  unnecessary  injury  to  soft  parts  of  palate.  The  removal  is  comjDar- 
atively  easy  in  a  child,  because  the  sutures  are  much  less  firm  (H.  Marsh). 
Arrest  hemoi-rhage,  pad  the  cavity,  replace  the  cheek  flap.  Suture.  Hare- 
lip pins  through  lip.  Prognosis. — Large  majority  of  cases  recover.  Chief 
dangers,  hemorrhage  and  blood-poisoning.  Death  on  operating-table  per- 
haps commoner  in  operations  about  jaw  than  in  any  others. 

Palatial  Excision  of  Upper  Jaw. — There  are  growths  which  affect  so  lim- 
ited a  part  of  the  upper  jaw  that  it  would  be  barbarous  to  remove  the 
whole  bone  for  them.  The  orbital  part  may  be  excised  and  the  palate  left, 
or  vied  versa.  Still  more  limited  operations  sometimes  suffice.  The  ex- 
ternal incision  is  done  in  the  same  line  as  that  for  total  excision,  but  made 
no  longer  than  is  necessary  in  each  case. 

Joints,  Diseases  of. — 1.  Acute  synovitis.  2.  Acute  suppuration  (or 
abscess,  or  acute  suppurative  synovitis).  3.  Acute  ostitis  of  a  joint  (inflam- 
mation of  the  articular  end  of  a  bone).  4.  Chronic  synovitis,  with  which 
is  usually  considered  Hydrops  articuli.  5.  Chronic  "joint  disease."  "White 
swelling.  Strumous  joint'  (including  both  "  pulpy  degeneration  of  syno- 
vial membrane,"  and  "  ulceration  of  cartilages").  6.  Chronic  rheumatic 
arthritis  (rheumatic  gout).  7.  Acute  rheumatism.  8.  Gout.  9.  Gonor- 
rheal rheumatism.  10.  Pysemic  arthritis.  11.  Puerperal  rheumatism  (from 
7  to  11  commonly  called  specific  inflammations).  Loose  cartilage.  An- 
kylosis. Neuralgia  of  joints.  Neuromimetic  or  hysterical  joint.  "Of  late, 
great  importance  has  been  attached  (especially  by  French  surgeons)  to 
speaking,  first,  of  diseases  of  the  synovial  membrane,  then  those  of  the 
cartilage,  articular  capsule,  and  bone,  corresponding  to  the  anatomical  con- 
ditions. Correct  as  this  division  would  be  if  it  were  only  a  question  of 
representing  the  pathological  anatomical  changes,  it  is  of  little  use  in  prac- 
tice. The  surgeon  always  views  inflammation  of  the  joint  as  a  whole,  and 
although  he  should  know  which  part  of  the  joint  suffers  most,  this  is  only 
a  part  of  what  he  should  know  ;  course,  symptoms,  and  constitutional  state 
equally  demand  his  attention  and  determine  the  treatment.  Hence  the  en- 
tire clinical  appearance  will  determine  the  divisions  of  this,  as  of  many 
other  diseases"  (Billroth). 

Acute  Synovitis. — Causes. — Usually  exposure  to  cold.  Often  blows  or 
sprains.  Predisposing  cause  sometimes,  e.g.,  syphilis,  rheumatic  constitu- 
tion, etc.     But  specific  inflammations  are  noticed  sepai'ately.     Joints  least 

'  These  terms  are  used  often  as  if  quite  synonymous.  But  some  surgeons  confine 
the  term  "strumous"  to  cases  in  which  they  believe  the  patient  is  originally  of  a 
scrofulous  constitution;  some  surgeons  would  discard  the  term  "strumous,"  al- 
together; and  some  even  use  clinically  such  terms  as  "  ulceration  of  cartilage,"  just 
as  if  such  a  term  described  a  primary  disease. 


154  JOINTS,    DISEASES    OF. 

suppKed  with  a  covering  of  soft  parts  are  most  liable.  Signs. — Pain,  heat, 
and  swelling,  but  not  usually  redness.  Great  tenderness.  Swelling  has  a 
characteristic  shape,  bulging  out  exactly  where  the  synovial  membrane 
would  tend  to  pouch  when  distended.  Fluctuation.  Tension  sometimes . 
great  enough  to  prevent  fluctuation.  Feverishness.  Pathology. — Synovial 
membrane  is  actively  congested,  and  cavity  of  joint  distended  with  sero- 
synovial  fluid,  usually  clear,  but  occasionally  containing  a  few  corj^uscles 
or  a  little  blood.  Prognods. — Altogether  good,  unless  constitution  be  bad 
or  treatment  neglected.  Diagnosis. — Distinguish  from  acute  inflammation 
of  any  neighboring  bursa.  Consider  position  and  shape  of  swelling  and 
history  of  case.  Treatment. — Rest ;  splint  or  "  fixed  apj)aratus."  Attend 
to  position  according  to  joint  affected.  Cold.  Pressure.  Wet  bandages. 
Cotton  wool  compress  and  bandage  over  it.  Leeches.  Hot  fomentations. 
Dover's  powders  internally.     For  specific  cases  give  specific  drugs. 

Acute  Suppukation  oe  Acute  Abscess  of  Joint. — Causes.— Sometimes 
one  or  more  of  the  causes  of  ordinaiy  acute  sjTiovitis.  Sometimes  the 
opening  into  the  joint  of  an  abscess  in  the  neighboring  soft  tissues  or 
bone.  The  commonest  cause  is  a  wound  of  the  joint.  Signs  and  Diag- 
nosis.— Acute  pain  and  swelling  ;  redness  and  oedema,  which  may  disguise 
fluctuation.  Fixation  in  some  position  peculiar  to  each  joint,  e.g.,  flexion 
and  external  rotation  in  case  of  knee-joint.  High  fever  and  rigors.  After 
a  time  fluctuation  appears,  not  only  in  the  joint,  but  often  also  in  its  neigh- 
borhood (secondary  abscesses).  High  fever  continues.  To  distinguish  a 
superficial  abscess  near  a  joint  from  acute  articular  suppiu'ation,  notice 
that  in  the  former  case  the  symptoms  are  so  locaHzed  that  some  part  of 
the  joint  will  be  accessible  to  examination,  and  be  found  healthy.  The 
centre  of  an  extra-articular  inflammation  wiU  perhaps  be  noticed  to  corre- 
spond to  some  bursa,  or  to  some  superficial  injury.  Prognosis. — Destruc- 
tion of  joint  very  probable.  Danger  to  Hfe  great  in  old  age,  if  joint  be  a 
large  one.  Danger  of  pynemia.  Best  result  that  can  usually  be  expected 
is  ankylosis  in  good  position.  Complete  recovery  from  early  stage  possi- 
ble. Patliology. — In  early  stage,  synovial  membrane  is  red,  greatly  swollen, 
l^uffy  and  infiltrated  with  corpuscles  and  serum.  Contents  of  joints  are 
synovia  mixed  with  more  or  less  pus.  In  later  stage,  synovial  membrane 
is  red,  covered  with  fibrous  rinds,  and  partly  ulcerated ;  the  contents  of 
the  joint  are  thick  yeUow  pus,  mixed  with  fibrous  floccuh,  the  cartilage 
is  breaking  down,  and  even  the  adjacent  cancellous  bone  inflamed.  Treat- 
ment.— If  called  to  the  case  early,  and  there  is  sufficient  reason  to  believe 
that  the  stage  of  actual  abscess  and  synovial  cavity  filled  with  thick  pus 
has  not  been  reached.  Anaesthetize  patient.  Place  the  joint  in  a  suitable 
position.  Pad  both  limb  and  joint  freely  with  cotton- wool.  Then  apply  a 
fixed  apparatus  (plaster-of-Paris,  or  starch  and  millboard)  from  near  the 
extremity  of  the  limb  to  a  considerable  distance  above  the  joint  affected. 
Be  extremely  careful  to  bandage  evenly.     Place  ice-bags  over  joint.     Give 


JOINTS,    DISEASES    OF.  155 

moriDhia  stibcutaneously.  Elevate  limb.  Great  benefit  is  often  derived 
from  extension  by  "weights.  If  the  case  is  more  advanced,  or  if  it  gets 
■norse  under  the  above  treatment,  and  if  the  evidence  of  abscess  in  the 
joint  is  unmistakable,  the  question  of  opening  the  joint  presents  itself. 
Grooved  needle  or  asj)irator  may  be  used  to  confirm  diagnosis.  XJuless  a 
di-ainage-tube  is  used,  make  free  incisions,  as  Gay  recommends.  Anti- 
septic precautious  very  desu-able.  Many  cases  calm  down  into  a  chronic 
state. 

Acute  Ostitis  of  a  Joint. — Inflammation  of  the  Articular  End  of  a  Bone. 
— Inflammation  of  spongy  bone-substance  adjacent  to  a  joint  is  very 
rarely  acute  ;  though  chi-onic  joint  disease  frequently  begins  in  the  bone. 
Causes.— Obscure,  when  the  affection  cannot  be  traced  to  injury.  Signs 
and  Pathology. — Those  of  Ostitis,  quod  vide.  Pain,  heat,  and  swelling. 
Redness  combined  with  oedema  when  suppui'ation  occurs.  Synovial  mem- 
brane of  adjacent  joint  becomes  implicated.  Effusion  into  joint.  In  child- 
hood, whole  articular  epiphysis  may  separate.  Partial  necrosis  more 
probable  in  adults.  Diagnosis. — The  disease  may  be  known  to  have  begun 
in  the  bone  by  the  thickening  of  that  part,'  and  by  the  history.  Prognosis. 
— Danger  of  acute  articular  abscess,  or  in  the  event  of  acute  inflammation 
being  allayed,  of  chronic  destructive  disease  of  the  joint.  Treatment. — See 
Inflammation  of  Bone.  Eest,  elevation,  cold,  painting  with  iodine,  etc. 
Perhaps  occasionally  abscess  may  be  prevented  from  opening  into  joint  by 
a  timely  opening  fi'om  without. 

Chronic  Synovitis.  Hydeops  Articuli. — Causes. — Same  as  those  of  acute 
synovitis,  of  which  affection  it  is  usually  a  sequel.  Signs. — Almost  alw^'S 
attacks  the  knee.  Yoiong  men  most  liable.  Swelling  and  fluctuation  of  all 
the  sjTiovial  pouches  of  the  joint.  Little  or  no  pain  or  tenderness.  The  use 
of  the  joint  is  sometimes  not  much  impeded,  but  it  usually  causes  fatigue  and 
pain.  Diagnosis. — From  white  swelling,  by  the  absence  of  apparent  thicken- 
ing of  the  articular  ends  of  the  bones,  of  signs  of  ulceration  of  cartilage, 
of  the  great  wasting  of  the  Umb  which  almost  always  occurs  in  chronic 
destructive  disease  of  the  joint,  but  above  all  by  amount  of  effusion.  In 
early  stage  age  should  be  considered.  Hydrops  occurs  chiefly  in  yotmg 
adults,  strumous  disease  mostly  in  children.  Prognosis. — Little  or  no 
danger  of  hydrops  articuli  leading  to  any  serious  joint  disease.  Rekipse 
after  cure  very  common.  Treatment. — Perfect  rest,  counter-irritation,  and, 
above  aU,  compression  with  the  strong  elastic  bandage.  By  means  of  a 
soft  elastic  bag  containing  water  and  placed  beneath  the  elastic  bandage, 
the  pressure  can  be  measiu-ed  and  regulated  to  a  nicety,  without  removing 
the  bandage.  I  have  found  the  hydraulic  pressui-e  of  a  column  of  water 
twenty-eight  inches  high  sufficient ;  but  this  point  must  vaiy  with  the 

'  It  is  not  really  the  bone  itself  which  is  thickened,  but  the  periosteum  and  soft 
parts  over  it. 


156  JOINTS,  Diseases  of. 

case.'  Scott's  dressing.  Failing  tliese  methods,  asjairation  may  be  com- 
bined with  elastic  pressure,  or  tapping  with  injection  of  iodine.  In  case 
of  knee-joint  insert  a  trochar  and  cannula  close  to  side  of  patella,  draw  off 
fluid,  inject  tinct.  iodi.,  aquae,  aa  3  ss.  Let  iodine  escape  after  three  to 
five  minutes,  according  to  amount  of  pain.  Now  put  up  limb  as  after 
punctured  wound  of  joint.  Splint,,  swing,  or  starched  bandage,  etc.  Iodine 
injection  is  dangerous  both  to  life  and  limb,  and  can  very  rarely  be  justifi- 
able.    Joint  may  be  tapped  and  drained  with  antisejDtic  precautions. 

Chronic  Joint  Disease. — White  Swelling.  Strumous  Disease  of  Joints. 
Including  Pulpy  Degeneration  of  Synomal  3Iemhrane,  "  Ulceration  of  Carti- 
lage" (and  Articular  Ostitis  when  it  leads  to  chronic  degeneration  of  the 
adjacent  joint). — To  any  one  more  familiar  with  chronic  joint  disease  in 
books  than  in  the  human  body,  the  above  long  heading  may  seem  unneces- 
sarily fraught  with  confusion.  But  I  trust  that  it  is  not  so  ;  for  although 
some  of  the  above  terms  represent  different  conditions  at  the  outbreak  of 
disease  and  for  a  short  time  afterward,  yet  these  different  commencements 
almost  always  tend  toward  the  same  course  and  termination,  viz.,  implica- 
tion of  every  element/  of  the  joint,  synovial  membrane,  cartilage,  bone- 
surface,  and  ligaments.  There  are  numbers  of  diseased  joints  which,  even 
when  exposed  to  the  eye  by  excision,  amputation,  or  death,  do  not  reveal 
the  origin  of  their  disorganization.  Moreover,  in  deciding  upon  a  plan 
of  treatment,  one  considers  not  so  much  what  was  the  commencement  as 
what  is  the  present  state  ;  not  what  was,  but  what  is,  determines  the 
decision.  Still  it  is  true  that  the  consideration  of  the  past  may  throw 
light  on  the  future.  Moreover,  examiners  sometimes  base  their  questions 
on  anatomical  pathology.  Therefore  care  ^vill  be  taken  in  the  following 
notes  not  to  lose  sight  of  anatomical  distinctions.  Causes. — Most  cases 
can  be  traced  to  blows  or  falls,  or  exposure  to  cold  or  wet.  Strumous 
constitution  predisjjoses.  As  any  acute  inflammation  of  a  joint  may  be- 
come chronic,  so  every  cause  of  acute  may  also  be  a  cause  of  chronic 
ai'thritis,  including  gonorrhoea  and  other  specific  influences.  But  it 
is  rare  for  gout,  syphilis,  or  acute  rheumatism  to  lead  to  destructive  in- 
flammation of  a  joint.  Pathology. — Commencement  may  be  in  synovial 
membrane  (usually  after  blows,  cold,  or  specific  disease),  or  in  ligaments 
(usually  after  sj)raius),  or  in  bone  (often  in  strumous  constitutions) ;  but, 
according  to  modem  pathology,  seldom  or  never  in  cartilage.  When  the 
synovial  membrane  is  affected  primarily,  the  result  is  Brodie's  "pulpy  de- 
generation of  synovial  membrane."  In  this  disease,  parts  of  the  synovial 
membrane  swell,  look  oedematous,  pulpy,  reddish-gray,  and  soft.  This 
condition  spreads,  eating  up,  so  to  speak,  the  underlying  cartilage.  The 
microscopical  structure  of  the  pads  and  tufts  of  swollen  synovial  membrane 

'  But  to  prevent  relapse  it  is  necessary  to  insist  upon  the  patient's  wearing  a 
common  elastic  bandage  round  his  joint  for  months  after  leaving  hospital. 


JOINTS,    DISEASES    OF.  157 

becomes  identical  with  that  of  vascular  granulations.  In  the  subjacent 
layer  of  cartilage  Avhich  is  in  process  of  conversion  to  the  same  granulation- 
tissue,  the  cartilage  cells  themselves  divide,  proliferate,  and  assist  in  the 
dissolution  of  the  matrix  of  their  own  cartilage.  In  this  way  the  pulpy 
tissue  reaches  the  bone.  The  process  does  not  stop  here,  but  the  bone  it- 
self inflames,  erodes,  and  now  the  joint  is  carious.  In  the  meantime  the 
ligamentous  structures  of  the  joint  have  been  softening,  thickening,  and, 
in  some  places,  perhaps,  yielding  to  the  encroachments  of  the  pulpy  tissue, 
which  may  even  j)ierce  the  skin  and  present  externally  as  a  fungous 
granulation.  At  the  same  time  that  the  synovial  outgrowths  are  destroy- 
ing the  cartilage,  destructive  inflammation  may  appear  in  the  articular 
lamella  of  the  bone,  so  that  the  cartilage  is  attacked  both  above  and  below, 
like  a  whale  between  a  "  thrasher  "  and  a  sword-fish.  When  the  disease 
begins  in  the  ligaments  it  is  usually  in  the  hip  or  knee  joints,  which  have 
internal  Hgaments.  From  these  it  spreads  to  either  the  synovial  mem- 
brane or  the  bone,  or  to  both.  Then  the  featiu'es  of  the  case  cease  to 
have  anything  to  distinguish  them  from  those  of  disease  originating  else- 
where. The  frequency  v.dth  which  disease  begins  in  the  ligaments  is  a 
point  not  yet  settled.  Disease  beginning  in  the  bone.  Ostitis  is  the  com- 
mencement of  most  cases  which  are  genuinely  strumous,  and  of  many 
cases  which  are  not  strumous  at  ail.  The  prime  appearances  are  those  of 
Inflammation  of  Bone,  quod  vide.  Sometimes  the  joint  becomes  implicated, 
because  the  inflammatory  action  in  the  articular  lamella  spreads  to  or 
separates  the  cartilage.  Sometimes  necrosis  or  caries  leads  to  abscess 
which  bvxrsts  into  joint.  The  course  of  events  leads  to  synovitis,  which 
spreads  all  round  the  joint,  to  pulpy  thickening  of  the  synovial  membrane, 
and  to  its  usual  results,  as  described  above,  on  both  faces  of  the  joint.  In 
rare  cases  the  bone  becomes  full  of  soft  tuberculous  matter.  However  the 
disease  may  begin,  if  it  go  on,  the  ligaments  give  way,  the  ends  of  the 
bones  become  displaced,  and  perhaps  necrose  wholly  or  partially.  Sup- 
pm-ation  and  the  formation  of  sinuses  often  do  not  occur,  especialty  when 
the  patient,  excepting  his  articular  disease,  is  healthy.  The  most  profuse 
suppuration  occurs  in  the  weakest  and  most  ill-nourished,  or  else  when 
acute  suppurative  synovitis  becomes  chronic.  Symptoms  and  Course. — 
Insidiousness  of  first  stage  (unless  affection  is  a  sequel  of  acute  disease).  In 
case  of  joints  of  lower  extremity,  limping,  occasional  complaints  of  pain  or 
weakness.  Surgeon  soon  detects  signs  of  synovitis,  marked  much  more 
by  thickening  of  synovial  membrane  than  by  effusion  into  joint.  See 
notices  under  names  of  individual  joints,  e.g.,  Hip-jomt.  Or  the  first 
symptoms  observable  may  be  those  of  articular  ostitis  {see  p.  155).  The 
limb  assumes  a  peculiar  appearance,  distinguished  by  the  swelling  and 
pallor  of  the  diseased  joint,  and  by  the  wasting  of  the  muscles.  The  joint 
assumes  a  bent  position.  At  a  later  stage,  dislocation  takes  place.  Sup- 
puration may  occur  at  any  time,  or  not  at  aU.    Sinuses.    Fungous  granula- 


158  JOINTS,    DISEASES    OF. 

tions.  When  bone  becomes  affected,  starting  pains  at  niglit,  excruciating 
pain  on  sudden  movement  or  on  pressing  joint-surfaces  together.  Some- 
times secondary  abscesses.  Grating  may  indicate  roughness  of  cartilages. 
Necrosis  may  be  guessed  at  from  the  histoi-y  or  from  occuiTence  of  marked 
crei^itus,  but  can  only  be  certainly  known  when  joint  is  open.  Probe  may 
detect  caries  when  granulations  cover  the  diseased  bone.  Granulations 
f ungating  through  a  sinus  almost  always  indicate  caries.  Prognosis. — 
Depends  on  (1)  patient's  constitution,  (2)  his  nutritive  condition,  (3)  his 
command  of  time  and  money,  (4)  the  joint  affected,  (5)  the  anatomical 
origin  of  the  disease,  (6)  the  treatment  adopted.  "Where  there  is  also 
phthisis  or  kidney-disease  the  case  is  almost  hopeless.  The  state  of  nutri- 
tion is  the  most  important.  Poor  patients  sometimes  cannot  afford  to 
wait  till  natui'e  cures  the  disease,  and  prefer  amputation  :  the  surgeon  can 
rarely  be  justified  in  acting  on  this  consideration.  Moreover,  fresh,  healthy, 
highland  or  sea  air  is  denied  to  ui'ban  jDOor.  Primary  osseous  disease  is 
of  worse  prognosis  than  syno^■ial.  Treatment. -^(jenexal  and  local.  General. 
— Indications :  (1)  to  improve  nutritive  condition,  (2)  to  obtain  best  i^os- 
sible  conditions  of  fresh  air,  cheerful  light,  sound  sleejj,  etc.  In  many 
cases  general  rest,  in  the  sense  of  total  confinement  to  bed,  not  desirable. 
Rather  combine  general,  outdoor,  moderate  exercise  with  local  rest.  But 
long  intervals  of  repose  and  gentleness  of  exercise  essential.  Cod-liver  oil, 
ii'on,  quinine,  milk,  etc.,  according  to  special  features  oT  case.  Local  Treat- 
ment.— Indications :  (1)  perfect  rest,  (2)  one  or  more  of  the  following 
remedies  :  A  fijm  plaster  case  over  a  flannel  bandage,  and  extending  from 
some  way  below  to  a  considerable  distance  above  the  joint  affected.  In- 
stead of  jDlaster-of-Pai'is,  starched  bandage  and  millboard  may  be  used. 
Scott's  dressing,  i.e.,  ung.  hydrarg.  co.,  rubbed  on  joint  and  then  strijis  of 
pitch  plaster  sjpread  on  leather  applied  to  it.  Gentle  uniform  pressure  ^ath 
elastic  bandage  such  as  "Martin's."  Hydraulo-elastic  pressure.  Extension 
by  weights.  Extension  by  Sayre's  splints.  Elevation.  Suspension  in 
Salter's  swing.  Continuous  cold  ;  ice-bags.  Counter-initation.  "Firing." 
Blisters.  When  acute  exacerbations  supervene,  a  few  sui'geons  recommend 
leeching.  Perfect  local  rest  not  always  desirable.  A  certain  amount  of 
gentle  or  of  passive  exercise,  combined  with  "  shampooing  "  and  the  elastic 
bandage,  better  for  some  cases  [see  Barwell  in  Practitioner,  vol.  xiii., 
p.  3G5).  At  a  certain  stage  arises  the  question  of  excision,  or  of  excision 
versus  amputation.  This  is  decided  by  considering  (1)  the  joint  affected  ; 
(2)  state  of  general  health;  (3)  state  of  kidneys,  lungs,  and  liver;  (4)  the 
stage  of  the  disease  ;  (5)  whether  operation  is  required  to  save  life  or 
merely  to  shorten  period  of  illness  and  treatment.  While  excision  may 
freqiiently  be  useful  in  the  elbow  and  hip,  and  sometimes  in  the  wTist,  it 
can  seldom  be  desirable  in  the  shoulder  (except  after  gunshot  wound  or 
comjjound  fracture)  ;  and  some  surgeons  never  excise  the  knee.  See 
articles  Excision  of  Joint  and  Amputation.    Swabbing  out  joint  with  dilute 


JOINTS,    DISEASES    OF.  159 

sulphuric  acid  (one  in  three).  Operative  measures  of  any  kind  rarely 
justifiable  until  joint  is  on  the  point  of  oj)ening  spontaneously.  Suppiu*a- 
tion  and  free  discharge  do  not  coimter-indicate  plaster  cases.  Small  win- 
do^TS  can  be  cut  in  the  case.  These  windows  should  be  really  small,  i.e., 
not  large  enough  to  spoil  the  case  as  a  uniformly  supjDorting  agent. 
Sinuses  may  be  slit  up  and  loose  pieces  of  necrosed  bone  removed. 

Cheonic  Rheumatic  Aktheitis — Rheumatic  Gout. — See  Rheumatism. 

GoNOREHCEAii  RHEUMATISM. — An  affection  of  the  joints  occuiTing  in  the 
course  of  a  gonorrhoea.  Relation  of  the  two  diseases  uncertain.  The 
arthritis  may  be  due  to  blood-jDoisoning,  or  to  reflex  iiTitation  through 
spinal  cord  ;  for  it  seems  that  various  affections  of  the  genitals  will  cause 
inflammations  of  the  joints.  Symptoms. — It  usually  attacks  knee,  hip, 
wrist,  ankles,  especially  knee.  Pain,  stiffness,  swelling,  heat ;  various  de- 
grees of  acuteness  or  of  chronicity.  Seldom  goes  on  to  suppuration  and 
disorganization  of  joint.  Usually  confined  to  synovial  membrane  and  hg- 
amentous  structxu-es.  Pathology. — The  appearances  of  synovitis,  ostitis,  or 
abscess  are  not  characteristic  of  their  gonorrhoeal  origin.  See  above  for 
pathology  of  Synovitis,  etc.  Prognosis. — Considerable  danger  of  ultimate 
ankylosis.  Often  complete  recovery.  Relapse  may  occur  if  gleet  return. 
Treatment. — Cui-e  the  gonorrhoea  or  gleet.  Make  the  urethra  aseptic  {see 
Gonorkhcea).  Treat  the  joint-affection  according  to  the  rules  given  above 
for  the  particular  form  of  joint-inflammation  each  case  of  gonorrhoeal  rheu- 
matism may  most  resemble.  When  chronic  arthritis  persists  after  gonor- 
rhoea is  cured,  great  benefit  often  derived  from  an  elastic  bandage,  and 
ten-grain  doses  of  pot.  iod.  ter  die. 

Note. — The  muscular  pains  often  occiu-ring  in  the  course  of  a  gonor- 
rhcea  are  by  some  classified  as  a  form  of  gonorrhoeal  rheumatism.  Cui*e 
the  cause,  and  direct  flannel  to  be  worn.  Chloral  may  be  necessary  at 
night.     Change  of  cHmate. 

Loose  Caktiiages. — Causes. — 1.  They  grow,  like  warts,  on  the  synovial 
membrane,  and  afterward  break  off;  (2)  they  are,  in  rare  cases,  chipped 
off  the  joint  cartilage  itself.  (3)  There  is  also  a  theory  of  theii-  formation 
by  a  process  identical  with  that  of  "Quiet  Necrosis"  (Paget's  "CHnical 
Lectures,"  p.  343,  and  Teale).  Symptoms. — Liability  to  sudden  and  sicken- 
ing attacks  of  jjain,  caused  by  certain  movements,  and  followed  by  synorial 
effusion.  The  loose  cartilage  may,  in  many  instances,  be  felt  near  the 
superficial  aspect  of  the  joint.  These  symptoms  make  the  diagnosis  quite 
clear.  Pathology. — Number  usually  single,  but  sometimes  very  numerous. 
Shape  rounded  or  flattened  with  rounded  edges.  Size  from  that  of  a  shot 
to  that  of  a  broad  bean,  or,  in  exceptional  cases,  much  larger.  Structure 
rarely  cartilaginous,  usually  fibrous.  Joint  most  commonly  affected,  the 
knee.  Treatment. — 1.  India-rubber  bandage  and  moderation  in  exercise  of 
joint,  especially  restraint  from  violent  motions.  Perseverance  in  this  may 
cause  permanent  cessation  of  unpleasant  symptoms,  perhaps  adhesion  of 


160  KIDNEY,    DISEASES    OF. 

the  loose  cartilage  to  a  convenient  part  of  the  joint.  2.  Operative.  This 
must  be  either  subcutaneous  or  antiseptic.  Subcutaneous  excision. — Fix 
the  cartilage  between  the  finger  and  thumb  ;  then  pass  a  tenotome  through 
the  skin  at  a  distance,  and  with  it  divide  the  capsule  of  the  joint  until  the 
cartilage  can  be  squeezed  out  into  the  ai'eolar  tissue.  Fix  it  there  by 
strapping,  etc.,  and  place  the  limb  on  a  splint,  or  in  a  plaster-of-Paris  cnse. 
A  week  afterward,  if  the  sui'geon  choose,  he  may  cut  out  the  cartilage  al- 
together,— See  Square,  Medical  Times,  vol.  ii.,  1857. 

Joints,  Neuromimesis,  or  Hysteria  of. — Diagnosisirom  "organic" 
disease  is  based  on  the  facts  that,  in  neuromimesis,  (1)  the  subjective 
symptoms,  pain,  tenderness,  etc.,  are  often  great  while  there  is  in  the  joint 
no  alteration  visible  to  the  surgeon  at  all ;  (2)  the  pain  and  tenderness  are 
often  chiefly  in  the  skin  rather  than  in  the  joint  itself ;  (3)  the  patient 
sometimes  describes  her  sufferings  in  strong  language,  but  in  a  cheerful 
manner,  as  though  the  recollection  of  them  was  not  so  very  painful  after  all ; 
(4)  stiffness  and  contractions  disappear  under  anassthetics  ;  (5)  instead  of 
being  hotter  than  the  healthy  joint,  as  in  the  case  of  inflammatioiis,  the  af- 
fected joint  is  often  colder  ;  (6)  other  hysterical  s^'mptoms,  and  even  a 
manifest  cause  for  them,  may  coexist.  But  bear  in  mind  that  hysterical 
patients  are  not  exempt  from  organic  disease,  and  that  "  hysteria  "  itself 
even  sometimes  leads  to  actual  alterations  in  the  joints.  This  is  not  sur- 
prising, considering  the  intimate  relations,  pathologically  as  well  as  physi- 
ologically, between  the  sj)inal  cord  and  the  joints.  Treatment. — See  Hys- 
TEKLV.     Eefer  to  Paget's  "  Clinical  Lectures." 

Kidney,  Diseases  of. — Frequently  complicate,  and  are  produced  by 
bladder  and  urethra  disorders,  especially  such  as  obstmct  the  flow  of  urine. 
Amyloid  kidney  is  a  common  result  of  prolonged  suppurations  and  of 
syphilis.  According  to  Marcus  Beck  (his  contributions  to  Erichsen's  "  Sur- 
gery," ed.  7,  vol.  ii.,  should  be  carefully  read),  such  diseased  conditions  of 
the  ureters  and  pelvis  of  the  kidneys  are  met  with  in  three  chief  forms,  A'iz.  : 
1,  the  results  of  simple  over-distension  without  acute  inflammations ;  2, 
acute  inflammation  without  signs  of  over- distension  ;  3,  a  combination  of 
the  two.  Simple  chronic  over-distension  leads  to  dilatations  with  a  certain 
amount  of  thickening.  The  conditions  of  the  kidney  are  classified  as  fol- 
lows :  1,  change  resulting  from  pressure  by  urinary  obstruction  ;  2,  acute 
interstitial  inflammation  ;  3,  acute  interstitial  inflammation  with  scattered 
abscesses  ;  the  result  of  former  acute  and  subacute  attacks,  from  which  the 
patient  has  recovered.  1.  Pressure  by  Urinary  Obstruction  causes  dilatation 
of  the  kidney,  absorption  of  the  pyramids,  cellular  infiltration  of  the  inter- 
tubular  tissue  (interstitial  nephritis),  and  little  or  no  change  in  the  tubules 
themselves  in  the  cortex.  Capsule  tough  and  adherent.  In  severe  cases 
even  the  cortex  is  almost  entirely  atrophied,  so  that  the  kidney  becomes  a 
mere  sac.  2.  Acute  Diffuse  Interstitial  Inflammation. — Kidney  soft  and 
swoUen ;  capsule  separates  readily,  but  kidney-substance  gives  way  during 


KIDIOJY,    DISEASES    OF.  161 

the  separation.  Surface  mottled ;  section  also  mottled ;  cortex  pale,  but 
pyramids  much  congested.  Microscopically,  great  celltilar  infiltration  be- 
tween the  tubuli.  In  many  parts  tubuli  are  seen  compressed  or  destroyed. 
Most  infiltration  around  Malpighian  bodies.  3.  Acute  Interstitial  Nephritis 
vnth  Scattered  Abscesses. — Frequently  coincident  with  acute  pyeHtis  and 
putrid  urine  in  pelvis  of  kidney.  Kidney  shows,  in  the  parts  affected,  signs 
of  the  condition  described  in  the  last  paragraph  (interstitial  nephritis),  and, 
in  addition,  scattered  groups  of  bright  yellow  spots.  These  spots  are  mi- 
nute abscesses.  In  certain  cases  this  disease  may  advance  to  general  sup- 
puration of  the  whole  kidney.  4.  Effects  of  Former  Attacks  from  which  the 
Patient  has  Recovered. — These  correspond  to  the  changes  which  result  from 
interstitial  inflammations  elsewhere.  In  mild  cases  complete  resolution  is 
possible  ;  but  in  more  severe  ones  cicatricial  fibroid  changes  make  the  kid- 
ney contracted  and  tough,  obliterating  many  of  its  glandvdar  elements. 
The  capsule  is  hard  to  separate  ;  many  small  cysts  lie  beneath  it ;  the  cor- 
tex is  greatly  thinned  ;  but  the  pyramids  are  little  altered.  Causes  of  In- 
terstitial Inflammation. — 1,  tension  ;  2,  reflex  irritation  ;  3,  septic  matter  in 
pelvis  of  kidney.  The  origin  of  reflex  irritation  in  these  cases  is  usually 
some  disease  in,  injuiy  to,  or  operation  on  the  bladder  and  prostatic  part 
of  the  urethra ;  but,  in  Beck's  opinion,  it  is  hkely  that,  "in  all  cases  of 
operation  on  the  urethra,  there  is  a  miniature  representation  of  that  intense 
congestion  of  the  kidney  which  is  fotmd  in  cases  of  death  from  suppression 
of  the  uiine  after  simple  catheterism." 

Symptoms  of  Kjdney  Disease  in  Suegical  Aitections  of  the  Genito- 
Urinaey  Organs. — Those  of  simple  dilatation  of  the  kidney  are  few.  The 
most  important  are  increased  quantity  and  diminished  specific  gravity  of 
the  urine.  The  urine  to  be  examined  should  be  collected  for  twenty-four 
hours.  Subacute  Interstitial  Nephritis  is  often  obscured  by  the  affection 
which  has  led  to  it,  e.g.,  by  vesical  catarrh.  But  even  in  such  circum- 
stances a  dry  tongue,  persistent  nocturnal  rises  of  temperature  (rarely  to 
above  101°  F.),  emaciation,  and  occasional  nausea,  are  ominous  symptoms. 
Urine  copious  ;  its  specific  gravity  usually  low. 

Acute  Interstitial  Nephritis  ivith  Scattered  Abscesses. — Begins  with  rigor 
and  rise  of  temperature  to  105°  or  106°  F.  This  may  be  repeated  again 
and  again.  Tongue  Hke  broiled  ham.  Sordes.  Nausea,  vomiting.  Rapid 
emaciation.  Possibly  diarrhoea.  So  called  "typhoid"  symptoms.  Ten- 
derness over  kidneys.  Muttering  delirium.  Patient  sinks  ;  but  the  pro- 
fovmd  coma  and  convulsions  of  urnemic  poisoning  are  excej)tional.  "  The 
urine  varies  much.  It  usually  becomes  more  or  less  bloody,  and  in  rare 
cases  is  suppressed,  though  much  more  frequently  a  considerable  quantity 
is  passed  up  to  the  time  of  death."  Much  decomposed  and  mixed  with 
mucus,  pus,  and  blood.  Diagnosis  has  to  be  made  from  (1)  pyaemia,  (2) 
peritonitis,  (3)  typhoid  fever,  (4)  ague.  "From  pyaemia  the  diagnosis 
is  somewhat  difficult,  the  most  important  point  beiag  the  vomiting,  the 
11 


162  KNOCK-KNEE. 

absence  of  secondary  abscesses,  the  drowsy  state  into  which  the  patient 
soon  falls,  and  the  fact  that  the  temperature  often  remains,  for  days  before 
death,  below  normal."  The  kind  of  vomiting  and  the  course  of  tempera- 
ture contrast  with  those  of  peritonitis.  The  temperature  curves  and  the 
absence  of  spots  distinguish  from  typhoid.  In  ague  there  should  be  com- 
plete intermissions.  Prognosis.  —  In  acute  cases  of  "surgical  kidney" 
always  bad,  but  most  so  in  suppurative  nephritis.  Treatment  of  kidney- 
disease  complicating  surgical  cases. — Kest.  Avoid  every  source  of  genito- 
urinary irritation.  If  catheterism  is  unavoidable,  use  soft  instruments, 
thoroughly  cleansed,  oiled,  and  antiseptic.  Treat  the  causes  with  mild 
and  gentle  means.  For  interstitial  nephritis,  dry- cup  the  loins,  give  pur- 
gatives, dress  in  flannel,  stimulate  the  skin,  e.g.,  by  hot-air  baths.  Shun 
surgical  operations. 

Knock-knee  (Genu  valgum). — A  deformity  in  which  the  knee  is 
bent  inward.  Causes. — Rickets  ;  muscular  weakness,  combined  with  habits 
of  excessive  standing,  or  of  carrying  heavy  burdens  ;  lazy  manner  of  walk- 
ing and  standing.  About  pubei-ty  a  disease  is  liable  to  attack  the  epiphy- 
seal cartUages,  somewhat  analogous  to  the  rachitis  of  childhood.  These 
cartilages  are  then  peculiarly  liable  to  give  way  from  the  causes  above 
mentioned.  Hence  many  cases  of  genu  valgum,  and  even  spinal  curva- 
ture, (See  IMikulicz  in  v.  Langenbeck's  Archiv,  xxiii.,  3  to  4  ;  and  also 
Busch:  "  Die  Belastungsdeformitjiten  der  Gelenke,"  Berlin,  1880.)  Anat- 
amy. — The  diaphyses  of  the  femur  and  tibia  grow  faster  on  the  inner  than 
on  the  outer  side.  Thus,  the  internal  condyle  is  pushed  downward,  and 
the  inner  part  of  the  upper  epiphysis  of  the  tibia  upward.  At  the  same 
time  the  diaphyses  often  grow  curved,  with  the  convexity  inward.  The 
patella  tends  outward  toward  the  external  condyle.  The  internal  lateral 
ligament  is  relaxed  in  cases  which  commence  at  or  near  puberty,  but  not 
in  the  knock-knee  of  rachitic  children.  Treatment. — In  early  age,  the  most 
severe  cases  can  usually  be  cured  by  judicious  and  persevering  use  of  splints 
or  irons,  and  elastic  force,  combined  with  tonic  medicines  and  hygiene. 
But  some  plan  of  osteotomy  has  to  be  followed  when  the  bones  are  hard.' 
Such  operations  are  (1)  Ogston's,  (2)  Chiene's,  (3)  McEwen's,  (4)  Reeves's, 
on  the  femur,  and  (5)  Barwell's,  on  femur,  tibia,  and  fibula.  M.  Delore 
forcibly  bends  the  knee  straight  during  anaesthesia,  and  then  secures  it  in 
a  movable  dressing.  He  says  that  this  procedure  separates  the  inferior 
epiphysis  of  the  femur.  Dr.  Ogston  makes  a  small  incision  through  the 
skin  and  saws  off  the  internal  condyle  subcutaneously,  and  then  easily 
brings  the  limb  straight.  McEwen  chisels  nearly  through  the  femur  above 
the  condyles,  and  then  puts  the  limb  straight.     This  is  a  very  satisfactory 

'  It  is  difficult  to  give  any  concise  and  precise  rules  or  indications  for  osteotomy  in 
genu  valgum.  In  each  case  the  age  of  the  patient,  the  amount  of  the  deformity,  its 
duration,  its  cause,  its  precise  anatomical  nature,  and  the  eflEect  upon  it  of  experi- 
mental splinting,  have  to  be  considered. 


LARYNX,    DISEASES    OF.  163 

Operation.  Use  antiseptics.  Chiene's  and  Reeves's  modes  of  operation 
differ  from  Ogston's  in  that  the  former  removes  a  wedge  of  bone  and 
therefore  alters  the  joint-surface  less,  while  the  latter  chisels  up. to,  but 
not  through,  the  articular  cartilage.  Chiene  uses  the  chisel.  (See  Oste- 
otomy in  Appendix.) 

Labia. — The  external  genital  organs  of  the  female  are  liable  to  (1) 
hypertrophy,  (2)  cystic  tumors,  (3)  venereal  diseases,  especially  warts  and 
ulcers,  (4)  epithelioma,  (5)h8ematocele,  (6)  varix,  (7)  abscess,  besides  other 
affections  of  less  frequent  occiirrence.  Affections  of  the  labia  are  modified 
by  (1)  the  vaginal  and  vesical  discharges  to  which  they  are  so  often  ex- 
posed ;  (2)  the  hindrance  to  the  circulation  due  to  the  dependent  position 
of  relaxed  or  hypertrophied  labia ;  (3)  the  dirty  habits  of  some  patients. 
In  treating  them,  beware  of  severe  parenchymatous  hemorrhage.  (See  ar- 
ticle Hemoerhage.) 

Cysts  of  the  labia  are  particularly  frequent  in  young  women,  especially 
shortly  after  marriage.  They  are  commonly  caused  by  hypertrophy  of  the 
folhcles  of  Cowper's  glands.  Lay  them  freely  open  and  insert  lint  in  the 
cavity. 

Hypertrophy  of  the  labia  or  of  the  clitoris  usually  originates  in  venereal 
inflammation,  but  persists  after  the  cause  is  removed.  Treatment. — Exci- 
sion.    Acupressure  may  be  used  to  repress  troublesome  hemorrhage. 

Congenital  Cohesion  of  the  Labia. — Easily  remedied  by  tearing  with  the 
handle  of  a  scalpel.  Oil  the  surfaces  well,  and  instruct  the  nurse  to  keep 
them  separate  with  a  piece  of  oiled  lint  for  a  few  days. 

Larynx,  Diseases  of. — Acute  catarrh  (acute  laryngitis).  Chronic 
catarrh  (including  clergyman's  sore-throat).  CEdema  glottidis,  syphilitic 
affections,  phthisis,  cancer,  inflammation  and  necrosis  of  cartilages,  tumors, 
foreign  bodies,  "  nervous  "  disorders  (including  laryngismus  stridulus). 

Larynx,  Acute  Catarrh  of — Acute  Laryngitis. — Causes. — Cold,  cold 
with  damp  ;  excessive  shouting,  speaking,  or  singing  ;  eiysipelas  spreading 
inward  to  larynx.  Mechanical  and  chemical  irritants.  Scalds.  Acute 
exacerbations  sometimes  supervene  in  cases  of  chronic  catarrh.  A  larynx 
diseased  from  any  cause  is  more  liable  to  acute  inflammation  than  a  sound 
organ.  Spread  of  a  naso-pharyngeal  catarrh  to  larynx.  Influenza.  Ex- 
anthemata, e.g.,  measles,  small-pox,  typhoid.  Symptoms. — Functional  de- 
rangements, viz.,  loss  of  voice  or  hoarseness.  Pain  in  throat  near  hyoid 
bone,  perhaps  tenderness  in  that  region  when  swallowing.  Tickling  in 
throat.  Hacking  cough.  At  first  scanty,  tenacious  sputa,  afterward  looser 
and  more  purulent.  If  the  case  progresses  unfavorably,  dyspnoea  comes 
on,  and  this  is  liable  to  sudden  and  most  dangerous  increase,  during  which 
tracheotomy  or  laryngotomy  may  be  necessary  to  prevent  asphyxia.  The 
local  symptoms  are  usually  much  more  serious  than  the  general.  But 
more  or  less  fever  is  present.  Pathology. — Whole  mucous  tract  of  larynx 
is  not  always  affected.     The  appearances  are  like  those  of  mucous  catarrhs 


164  LARYNX,    DISEASES    OF. 

elsewhere,  i.e.,  swelling,  redness,  mucous,  purulent,  or  sero-purulent  ex- 
udation ;  occasionally,  in  severe  cases,  smaU  submucous  hemorrhages. 
The  dyspnoea  mentioned  above,  when  sudden,  is  partly  or  whoUy  spas- 
modic. But  the  most  dangerous  kind  results  from  great  serous  effusion  in 
the  submucous  tissue  of  the  glottis,  "  oedema  glottidis."  After  death  the 
appearances  are  much  less  marked  than  when  shown  by  the  laryngoscope 
during  life.  Diagnosis. — Hoarseness,  and  occasionally  dyspnoea,  indicate 
larynx  as  the  seat  of  affection.  Laryngoscope  will  exhibit  actual  state  of 
organ.  Catarrhal  laryngitis  differs  from  croup  in  that,  1,  the  dyspnoea  is 
not  persistent,  and  varies  more  ;  2,  there  is  no  false  membrane  ;  3,  there  is 
usually  less  fever  ;  4,  a  known  cause  and  history  may  point  unmistakably 
to  acute  non-croupous  laryngitis.  Prognosis. — Very  guarded,  danger  of 
sudden  and  fatal  dyspnoea.  Laryngotomy  and  tracheotomy,  while  they 
avert  this  danger,  introduce  others,  such  as  pulmonary  congestion.  Re- 
covery usually  complete,  but  acute  sometimes  passes  into  chronic  catarrh. 
Treatment. — Rest  in  a  room  of  uniform  and  warm  temperature.  Atmos- 
phere charged  with  steam.  Hot  moist  sponge  to  throat.  Low  diet.  Milk 
and  soda-water.  Avoid  greasy  food.  Salt  food  and  saline  drinks  benefi- 
cial Emetics  :  ipecacuanha,  tartar  emetic.  Aconite  {see  Ringer's  "  Thera- 
peutics," p.  399).  Diaphoretics.  Purgatives.  Forbid  attempts  to  speak  or 
whisper.  If,  in  spite  of  treatment,  dangerous  dyspnoea  should  come  on, 
perform  tracheotomy.     (For  (Edema  Glottidis,  see  "p.  165.) 

Lak\tix,  Chkonic  Catarrh  of — Chronic  Laryngitis — Clergyjian's  Sore- 
throat. — Causes. — Same  as  those  of  acute  catan-h.  But,  in  order  to  pro- 
duce the  chronic  affection,  they  have  to  be  applied  in  a  milder  fonn,  and 
more  persistently  or  repeatedly.  In  addition  to  these,  alcoholism,  syphi- 
lis, phthisis,  and  occupations  in  which  the  voice  is  frequently  strained, 
predispose  to  the  affection.  So  also  does  a  low  tone  of  the  ner\-ous  and  vas- 
cular systems.  Damp,  cold  climates.  Herpetic  diathesis.  Symptoms. — 
Hoarseness  ;  weakness  of  voice  ;  voice  also  loses  its  firmness  and  becomes 
uncertain,  especially  in  the  higher  notes.  Liability  to  intercurrent  at- 
tacks of  acute  laryngeal  catarrh.  Catarrh  usually  affects  also  the  neigh- 
boring mucous  tract  of  the  pharynx.  Dii'ect  observation  of  the  pharynx 
with  the  unassisted  eye,  and  of  the  larjTix  with  the  laryngoscope,  shows 
the  mucous  glands  enlarged,  a  dusky,  congested  mucous  membrane,  small 
varicose  veins,  and  a  glairy,  mucous  secretion  clinging  to  parts  of  the  re- 
gion. A  troublesome,  tickling  cough  sometimes.  Almost  always  a  habit 
of  clearing,  or  rather  of  attempting  to  clear  the  throat  by  hawking.  Thirst. 
Frequently  a  hypochondriacal  state  which  exaggerates  the  subjective  symp- 
toms. Often  symptoms  pointing  to  the  cause  of  the  chronic  laryngitis, 
e.g.,  signs  of  alcoholism.  Pathology. — ^Inflammatory  congestion  and  eventu- 
ally thickening  of  the  submucous  tissue.  Hypertrophy  of  the  mucous 
glands.  A  glairy  mucous  or  muco-purulent  secretion  clinging  to  the  mu- 
cous membrane.     Rai*ely  ulceration,  unless  the  disease  has  a  specific  cause. 


LARYNX,    DISEASES    OF.  165 

Varicosities  of  the  small  vessels.  Diagnosis. — Compare  symptoms  with 
those  of  specific  diseases  of,  and  with  those  of  ulcers  and  of  growths  in, 
larynx.  Prognosis. — Only  good  when  the  causes  can  be  removed  or  a 
change  of  cHmate  can  be  obtained,  or  local  treatment  persistently  carried 
out  for  a  long  period  by  skilled  hands.  Treatment. — Rest  from  irregular 
or  much  speaking  or  singing.  All  the  ordinary  precautions  against  catarrh, 
viz. : — good  thick  boots,  warm  socks,  dry  clothes,  dry  lodging,  dry  climate 
if  possible.  Exercise  in  fresh  air  without  thick  covering  on  throat,  but 
merely  a  thin  tie  or  handkerchief.  Regular  habits.  Avoid  night  air. 
Open  bowels.  Moderate  diet.  No  stimulants.  In  a  few  cases  generous 
diet  is  beneficial.  Gargling  with  hot  (not  lukewarm)  saline  solutions, 
especially  of  chlorate  of  potash ;  sponging  pharynx  and  glottis  with  soL 
argent,  nit.  (gr.  xx.  to  §  j.).  Inhalations  of  medicated  sprays  (especially  ar- 
gent, nit.,  gr.  j.-x.  to  3  j.),  or  of  chloride  of  ammonium  vapor.  Painting 
pharynx  •with  glycerine  of  tannic  acid.  The  health  of  the  other  organs 
and  systems  of  the  body  should  always  be  inquu'ed  into  carefully  and  at- 
tended to.  Chloride  of  ammonium,  belladonna,  mercury,  sulphur,  ipecac- 
uanha, antimony,  iodide  of  potassium,  are  all  sometimes  beneficial. 

(Edema  Glottedis. — Causes. — Usually  some  ulceration  or  deeper  affec- 
tion of  the  larynx  than  mere  non-specific  catarrh,  e.g.,  syphilitic  disease  of 
the  cartilages,  small-pox.  Sometimes  erysipelas  spreading  iaward  from 
face.  Scalds.  The  oedema  often  supervenes  quite  suddenly  in  the  course 
of  such  diseases.  Signs. — Firstly,  there  are  the  symptoms  of  the  original 
disease,  e.g.,  hoarseness,  loss  of  voice,  cough ;  then  gradually  or  quickly, 
signifying  the  occurrence  of  "  oedema,"  there  appears  great  dyspnoea,  al- 
most entirely  inspiratory.  This  assumes  a  fearful  form  ;  and  the  patient's 
attitude  and  expression,  as  he  exerts  every  muscle  to  get  breath  and  avoid 
the  strangulation  which  appears  to  him  imminent,  are  never  to  be  forgot- 
ten. Diagnosis. — From  croup.  The  latter  occui-s  in  children,  but  oedema 
glottidis  almost  always  in  adults.  On  pushing  the  fiLnger  boldly  into  the 
pharynx,  and  feeling  behind  the  back  of  the  tongue,  the  epiglottis  and  ary- 
tseno-epiglottidean  folds  may  be  felt ;  the  former  as  a  median  pear-shaped 
sweUing,  and  the  latter  as  two  lateral  elastic  swollen  rolls  of  distended 
membrane.  In  the  cases  where  the  oedema  is  unilateral,  of  course  a  swell- 
ing will  only  be  felt  on  one  side.  The  swollen  epiglottis  is  sometimes 
visible.  Pathology. — The  oedema  results  from  what  is  called  collateral 
fluxion,  that  is,  from  the  active  congestion  which  is  apt  to  take  place  near 
a  centre  of  inflammation,  especially  an  ulcer.  Niemeyer  aptly  draws  at- 
tention to  its  analogy  with  oedema  of  the  prepuce  complicating  a  chancre. 
The  swellings  may  be  pale  or  red,  according  to  whether  efiusion  or  hyperas- 
mia  predominates.  Treatment. — Scarify  with  a  bistoury  wrapped  round 
all  but  the  point  by  lint  or  strapping.  If  the  case  is  not  urgent,  croton  oil 
may  be  given  ;  and  an  emetic  when  there  are  many  moist  rales  indicating 
bronchial  and  pidmonary  congestion.     Warmth  to  the  extremities.     Pa- 


166  LARYNX,    DISEASES    OF. 

tient  should  swallow  slowly  small  bits  of  ice.  Whether  the  symptoms  are 
urgent  or  not,  he  should  be  carefully  watched  and  surgical  assistance  be 
at  hand  ;  for  tracheotomy  may  be  required  very  suddenly  to  save  from  in- 
stant suffocation.  When  the  above  plan  of  treatment  does  not  arrest  the 
disease,  perform  tracheotomy.  The  prognosis  after  operation  is  hopeful. 
{See  also  treatment  of  Acute  Laeyngitis.) 

Larynx,  STPmLmc  Aitections  of. —  Varieties. — (A)  secondary  affections — 
erythema,  condylomata,  ulcers  ;  (B)  tertiary  affections — "  papulo-tubercu- 
lar  elevations,"  ulcers,  gummata,  perichondritis,  necrosis  of  cartilages.  Sec- 
ondary affections  may  be  suspected  from  the  altered  voice,  combined  with 
secondaiy  ei'uptions  elsewhere,  especially  in  the  fauces.  They  can  be  seen 
with  the  aid  of  the  laryngoscope,  and  require  ordinary  constitutional  anti- 
syphilitic  treatment,  aided  in  some  cases  by  such  local  treatment  as  inhala- 
tions of  calomel  vapor,  sprays  of  chloride  of  ammonium  and  corrosive 
sublimate,  or  applications  of  nitrate  of  silver.  Fatigue  of  the  voice  should 
be  avoided.  Tertiary  affections  of  the  larynx  are  more  destructive  and  dan- 
gerous. The  papulo-tubercles  affect  any  part  of  the  laryngeal  mucous 
membrane,  and,  though  occasionally  causing  dyspnoea,  chiefly  signify  their 
presence  by  affecting  the  voice. 

Tertiaky  Ulcers  of  the  larynx  begin  either  superficially,  or  from  soft- 
ened gummata,  or  from  perichondritis.  Usually  multiple  ;  generally  first 
attack  epiglottis.  Spread  in  any  or  every  direction,  destroy  vocal  cords, 
necrose  cartilages.  Cause  dangerous  and  suffocative  spasms.  Symptoms. — 
Hoarseness  or  loss  of  voice  ;  in  many  cases  attacks  of  dyspnoea  ;  coincident 
syphihtic  history,  and,  usually,  syphilitic  appearance.  Swallowing  some- 
times diJSicult  from  tendency  of  fluids  to  pass  through  glottis.  Prog- 
nosis.— In  favorable  cases,  cicatrization  takes  jilace  ;  but,  even  then,  voice 
remains  impaired,  and  a  stricture  of  larynx  may  result,  seriously  impeding 
respiration.  So  long  as  disease  is  active  there  is  gxeat  danger  of  sudden 
and  fatal  spasm.  Diagnosis  has  to  be  made  chiefly  from  phthisis  and  epi- 
thelioma. Treatment. — Where  there  is  dyspnoea  which  cannot  be  rapidly 
removed  by  milder  means,  it  is  dangerous  to  delay  laryngotomy  or  trache- 
otomy. Usually  the  former  operation  is  to  be  preferred.  Iodide  of  po- 
tassium (grs.  X.  to  XX.  ter  die)  must  be  given  ;  cod-liver  oil,  tonics,  best 
hygienic  conditions  which  can  be  obtained,  are  indicated.  Locally,  astrin- 
gent, stimulant,  and  mercurial  appUcations  may  be  made  with  the  aid  of 
the  laryngoscope,  e.g.,  strong  solutions  of  sulphate  of  copper.  McEwen 
has  lately  (in  British  Medical  Journal  for  July  24  and  31, 1880)  demonstra- 
ted that  tracheal  tubes  introduced  through  the  mouth  may  be  vfsed  as  a 
substitute  for  tracheotomy  or  laryngotomy  in  cases  both  of  disease  and  of 
operation.  Laryngeal  strictures  have  been  treated  by  the  passage  of  metal- 
lic and  vulcanite  instruments  (Trendelenburg  and  Schrotter). 


LARYNX,    DISEASES    OF. 


167 


Tertiary  Ulcer, 
1.  Attacks  epiglottis  first. 


2.  Progresses  rapidly. 

3.  Little  thickening. 
4. 


5.  Expectoration  thick,  te- 
nacious, yellowish. 


Phthisical  Ulceratiok. 

Attacks  first  near  arytenoid 
cartilages. 

Does  not  advance  rapidly. 

Great  thickening. 

Granular  appearance  of  pos- 
terior surface  of  epi- 
glottis. 

Expectoration  frothy,  thin, 
muco-purulent. 


Epithelioma. 

Usually  commences  over 
pharyngeal  aspect  ol' 
arytenoids. 

Progress  slow. 

Irregular  thickening. 


At  first  thin,  often  bloody. 


Laryngeal  Phthisis. — Vide  medical  works  or  special  treatises.  Tlie 
diagnosis  mainly  rests  on  the  coexistence  of  pulmonary  disease  and  of 
hectic  fever,  on  the  absence  of  specific  disease,  such  as  syphilis,  and  on  the 
laryngoscopic  appearances.  The  latter  may  show  ulcerations,  especially  at 
the  back  of  the  epiglottis  and  near  the  arytenoid  cartilages.  The  disease 
is  tuberculous ;  though  it  may  be  the  result  of  local  infection  by  phthisical 
sputa  passing  over  laryngeal  mucous  membrane.  Treatment  is  addressed 
locally  to  the  ulcerations  and  chronic  laryngeal  catarrh  (vide  above),  and 
generally  to  the  phthisis. 

Larynx,  Cancer  of.  ' — Affects  chiefly  male  sex,  and  almost  always  occurs 
in  late  middle  life.  Begins  usually  on  left  side.  Primary  cancer  is  about 
as  often  encephaloid  as  epithelioma,  seldom  or  never  schirrus.  The  diag- 
nosis has  to  be  made  from  laryngeal  phthisis  and  from  syphilis.  Phthisis 
causes  earlier  and  more  complete  loss  of  voice.  Before  there  is  much  evi- 
dent new  growth  it  is  next  to  impossible  to  distinguish  laryngeal  cancer 
from  syphilis.  There  are  symptoms  analogous  to  those  of  cancer  else- 
where, viz.  : — pain,  offensive  odor,  hemorrhages,  glandular  enlargements. 
Treatment. — "While  the  diagnosis  is  at  all  doubtful  give  an ti- syphilitic  reme- 
dies. Afterward,  morphia  subcutaneously  for  pain,  carbolic  acid  inhala- 
tions for  fetor,  atomized  solutions  of  tannin  for  hemorrhages.  But,  above 
aU,  tracheotomy,  which  in  Fauvel's  cases  prolonged  hfe,  on  the  average, 
two  years  in  epithelioma  and  nine  months  in  encephaloid.  See  treatment 
of  Cancer.  The  results  of  operation  of  extirpation  of  larynx  have  not  yet 
been  encouraging. 

Laryngeal  Cartilages,  Perichondritis  and  Necrosis  of.  —  Causes. — 
"  Catching  cold,"  syphilis,  exanthemata.  La  directly,  any  cause  of  laryn- 
geal ulceration  ;  for  perichondritis  may  supervene  on  ulcer  of  larynx. 
Patients  are  usually  in  a  cachectic  state.  Signs,  etc. — Firstly  those  of  in- 
flammation :  pain  very  great. — Then  suppuration  :  collection  of  pus  may 
cause  intense  dyspnoea.  Lastly,  necrosis  of  cartilage,  which  varies  from 
very  trifling  extent  to  the  loss  of  whole  cartilages.  Portions  of  cartilage 
are  coughed  up.     Sinuses  may  form  in  neck.     Cricoid  cartilage  most  fre- 


'  See  especially  :  Fauvel's  Traite  Pratique  des  Maladies  du  Larynx.     Paris ; 
lahaye  ;  and  a  review  of  the  same  work  in  Medical  Record,  vol.  iv. ,  p.  476. 


De- 


168  LARYNX,    DISEASES    OF. 

quently  affected.  The  immediate  cause  of  the  necrosis  is  usually  sepa- 
ration of  inflamed  perichondrium  rather  than  inflammation  of  cartilage 
itself.  Diagnosis. — Easy  when  necrosis,  with  abscess  or  sinus,  is  fuUy 
advanced.  But  earher  stages  are  accompanied  by  signs  of  laryngeal  irri- 
tation, which  may  resemble  those  caused  by  a  foreign  body.  Use  laryngo- 
scope and  consider  history  of  case.  Treatment. — On  general  principles. 
Open  abscess.  Perform  tracheotomy  if  dyspnoea  is  urgent  and  dangerous. 
Treat  syphilis  if  present. 

Lakynx,  Innocent  Tumoks  of. —  Varieties. — Fibrous  and  fibro-sarcomatous 
polypi,  adenomata,  papillomata,  mucous  cysts.  Fibrous  polypi  and  papil- 
lomata  are  the  most  common.  Other  yarieties,  such  as  lipomata,  occur 
with  extreme  rarity.  Cancerous  tumors  are  described  elsewhere.  Posi- 
tion.— Very  rarely  on  the  posterior  wall  (where  vilcers  are  very  frequent). 
Signs. — Dyspnoea  when  the  tumor  is  large  enough  or  so  situated  as  to  be 
liable  to  get  between  the  vocal  cords.  When  the  tumor  is  above  the  glottis 
inspiration  is  most  likely  to  be  obstructed,  when  below  the  glottis  the  dypp- 
,noea  may  be  expiratory.  Sensation  as  if  foreign  body  were  in  larynx. 
Sometimes  secondary  laryngeal  catarrh :  cough,  hoarseness,  aphonia. 
iHagnosis. — Use  laryngoscope.  Treatment. — Kemoval  through  the  mouth 
in  most  cases.  Sometimes  the  larynx  has  to  be  opened  from  the  neck,  by 
median  division  of  the  thyroid  cartilage  for  instance.  In  removing  through 
the  mouth,  snares,  ecraseurs,  laryngeal  forceps,  guillotines,  and  even  gal- 
vanic cautery  are  used.  Of  course  the  parts  have  to  be  made  visible  by 
laryngoscope  during  operation,  and  no  small  skill  is  usually  required.  See 
special  notice  of  Lakyngoscopt.  Puncture  cysts.  Tracheotomy  is  done 
prior  to  thyrotomy,  and  may  be  required,  in  case  of  severe  dyspnoea  from 
tmnor,  merely  to  avert  immediate  danger  of  life. 

Lartnx  (Trachea  or  Bronchi),  Foreign  Bodies  in. — How  They  Gain  En. 
trance. — Through  glottis,  or,  very  rarely,  through  a  wound.  Children 
most  Hable,  from  practice  of  playing  with  things  in  their  mouths.  Laugh- 
ing or  coughing  whilst  swallowing  :  the  deep  inspirations  taken  in  those 
actions  suddenly  draw  food  into  the  air-passages.  Syphilitic  ulceration 
may  impair  laryngeal  orifice  or  sphincters.  General  palsy  of  the  muscles 
which  close  the  glottis.  Palsy  of  the  vocal  cords  is  not  in  itself  enough  to 
cause  any  danger  of  entrance  of  foreign  body.  Parts  Where  They  Lodge. 
— Sharp  bodies  usually  stick  in  larynx,  especially  in  or  near  the  ventricle, 
or  just  above  the  glottis.  Of  course,  only  bodies  of  limited  size  can 
pass  through  glottis.  Small,  smooth,  rounded  bodies  most  likely  to  drop 
into  trachea  or  bronchi,  especially  into  right  bronchus.  Septum  between 
bronchi  is  to  left  of  middle  line.  Eight  bronchus  is  larger  than  left. 
Signs. — Depend  (1)  upon  size  of  body,  (2)  upon  its  position,  (3)  upon 
whether  it  is  impacted  or  not,  (4)  upon  its  nature,  whether  sharp  and 
jagged  or  smooth  and  rounded.  1.  A  sufficiently  large  substance  wiU 
cause   speedy   suffocation  unless   removed.     2.  Bodies  near   the   glottis 


LARYNX,    DISEASES    OF.  169 

usually  cause  acute  irritation,  spasm,  cough,  and  choking  sensation ;  per- 
haps hemorrhage  and  pain.  Symptoms  may  be  aggravated  by  each  act 
of  swallowing.  If  not  removed,  ulceration,  catarrh,  or  even  abscess  will 
ensue.  Impaction  in  the  trachea  causes  signs  mainly  of  impeded  respira- 
tion, but  also  produces  general  laryngo-tracheal  irritation,  and,  eventually, 
inflammation  and  ulceration.  The  interference  with  respiration,  as  well  as 
the  tracheitis,  soon  affects  the  lungs.  Bronchitis  and  pneumonia.  When  a 
bronchus  is  the  locality,  the  signs  resemble  those  of  foreign  body  in  the 
trachea ;  but  the  pulmonary  symptoms  are  confined  to  or  most  marked  in 
one  lung.  There  is  decrease  or  absence  of  respiratory  murmur  on  the  af- 
fected side.  3.  Bodies  lying  loose  in  the  air-passages  are  apt,  as  they 
from  time  to  time  come  in  contact  with  the  glottis,  to  cause  sudden  and 
violent  paroxysms  of  choking  and  dyspnoea.  4.  Of  course,  sharp  and 
jagged  bodies  produce  greater  irritation,  and  cause  far  greater  danger  of 
ulceration,  etc.,  than  smooth  ones.  Diagnosis. — The  history  generally 
makes  this  clear.  Laryngoscope  is  very  valuable.  Lay  stress  upon  the 
sudden  access  of  the  symptoms  without  warning,  and  on  the  absence  of 
fever.  Of  course,  when  inflammation  has  resulted,  fever  will  be  present. 
Prognosis. — Most  grave,  unless  the  body  can  be  removed.  The  instances  in 
which  substances  have  remained  without  producing  serious  consequences 
are  very  rare.  Sooner  or  later  disease  of  the  lungs  ensues  and  proves 
fatal.  Treatment. — Measures  must  be  taken  to  remove  the  foreign  body. 
In  some  cases  the  finger  suffices  to  hook  away  an  obstruction  partly  within 
and  partly  without  the  larynx.  In  adults,  the  laryngoscope  will  some- 
times enable  forceps,  hooks,  or  loops  to  be  used  successfully  ;  and,  in 
children,  inversion  of  the  body  (applied  by  Mr.  Brunei  to  himself)  should 
be  tried,  aided  by  succussion  and  by  slapping  the  back.  The  remaining 
proceeding  is  tracheotomy.  And,  when  employing  inversion,  succussion, 
etc.,  the  surgeon  should  always  be  prepared  to  do  tracheotomy  at  a 
moment's  notice.  If  the  foreign  body  is  in  the  trachea  or  bronchi,  do 
tracheotomy  low  down.  If  the  foreign  body  be  in  the  larynx,  and  cannot 
otherwise  be  extracted,  the  tracheal  wound  may  be  extended  upward, 
even  through  the  thyroid  cartilage  itself.  If,  when  the  wound  has  been 
made,  extraction  cannot,  even  with  the  help  of  inversion  and  succussion, 
be  effected,  the  wound  must  be  kept  open  in  the  hope  that  the  patient 
may  shortly  cough  out  the  body.  And  a  cannula  must  not  be  worn  unless 
the  foreign  body  is  known  to  be  above  the  wound. 

Rules  for  Laeyncjoscopy.' — 1.  Position  of  patient :  sitting,  body  and 
head  erect,  knees  together,  head  slightly  thrown  back.  2.  Lamp  :  in  line 
with  patient's  ear,  nine  inches  to  left  of  his  head.  3.  Position  of  surgeon  : 
opposite  patient,  with  mirror  properly  adjusted  to  head  and  eye.  4. 
Mouth  :  wide  open,     5.  Reflect  hght  upon  fauces  at  correct  focal  distance 

'  Abbreviated  from  Lennox  Browne. 


170  LITHOTOMY. 

of  reflector.  6.  "Warm  laryngeal  mirror  over  lamp.  Test  it  against  cheek 
or  hand.  7,  Direct  patient  to  protrude  his  tongue.  8.  Hold  it  between 
thumb  and  index-finger,  in  napkin  (thumb  uppermost).  9.  Hold  laryngeal 
mirror  like  a  pen.  10.  Place  its  back  gently  against  uvula.  11.  Move  your 
hand  sHghtly  toward  patient's  left,  so  as  to  keep  it  out  of  line  of  view. 
12.  Patient  to  draw  a  deep  breath,  and  say  "  ah,"  "  ur,"  "  eh,"  or  "  ee."  Be 
always  quiet  and  gentle  ;  encourage  the  patient ;  let  each  examination  be 
short,  even  if  xmsuccessful.  Be  careful  not  to  hurt  patient's  tongue,  or  to 
burn  his  mouth,  or  to  push  either  his  uvula  or  the  mirror  against  the  back 
of  the  pharynx. 

Lakyngotomy. — Steady  larynx  between  thumb  and  forefinger  of  left 
hand.  Make  a  perpendicular  incision  through  skin  and  fascia  over  crico- 
thyroid membrane,  and  one  inch  long.  Pass  a  sharp  scalpel  through 
crico-thyroid  membrane  transversely.  In  the  absence  of  a  cannula  {e.g., 
ia  operations  done  vdth  a  penknife  to  prevent  choking),  turn  the  blade  on 
edge  to  hold  open  the  woiind.  In  operations  done  deliberately,  of  course 
some  tube  must  be  introduced.  See  Tracheotomy.  Tie  any  bleeding  ves- 
sel as  soon  as  it  is  divided. 

Lips  ai-e  hable  to  congenital  deformities  (vide  Hake-lip),  to  fissures, 
chancres,  epithehomata,  cysts,  naevi,  wounds,  carbuncles,  etc.  See  general 
articles,  e.  g.,  Txjmor,  Cystic,  etc. 

Fissure  of  Lip. — Often  syphihtic.  Avoid  laughing.  Touch  with  argent, 
nit. ;  afterward  use  weak  ung.  hyd.  nit.,  cold  cream,  etc.  Antisyphihtic 
remedies  if  necessary.  Make  a  shallow  cut  through  base  in .  obstinate 
cases. 

Carbuncle  of  Lip  is  singulai'ly  fatal     See  Carbuncle. 

Litholapaxy  (or  Lithotrity,  with  immediate  evacuation).— Professor 
Bigelow,  considering  that  the  practice  of  leaving  sharp  fragments  in  the 
bladder  for  weeks  was  more  hurtful  than  the  prolonged  use  of  the  litho- 
trite,  evacuating  catheter  and  bottle ;  being  struck,  moreover,  by  Otis' 
emphatic  announcements  of  the  great  cahbre  of  the  urethra — developed 
this  operation.  He  uses  a  special  lithotrite,  an  evacuating  catheter  of  a 
size,  if  possible,  of  No.  30  (French),  and  an  aspirating  siphon,  which 
stands  on  a  table  and  communicates  with  the  evacuating  catheter  by  an 
india-rubber  tube.  Ether  is  given,  and  the  sitting  may  be  prolonged  for 
an  hour.  There  are  many  details  to  be  attended  to.  Vide  a  Paper  by  Bige- 
low, in  "  CHnical  Society's  Transactions,"  vol.  xii.,  1879.  Facts  so  far  in- 
dicate an  excellent  future  for  this  operation.  See  also  observations  by  Sii- 
H.  Thompson  and  IMr.  Cadge  at  the  meeting  of  the  British  Medical  Asso- 
ciation, Cambridge,  1880. 

Lithotomy. — Definition. — An  operation  in  which  the  bladder  is  cut 
into  for  the  extraction  of  a  calculus.  Varieties. — Two  kinds,  viz.,  supra- 
pubic and  perineal  (vaginal  in  the  female).  Varieties  of  perineal  lith- 
otomy, viz.,  (1)  lateral,  (2)  median,  (3)  bilateral,  (4)  medio-lateral.     Bilat- 


LITHOTOMY,  1 71 

eral  lithotomy  is  so  rai*ely  employed  that  we  must  refer  to  larger  works 
for  a  description  of  it. 

Lateral  Lithotomy  (by  far  the  commonest  operation). — Instruments. — 
"  Staflf,"  grooved  on  side  or  on  convexity,  lithotomy  knife,  lithotomy  for- 
ceps, scoop,  bandages  or  straps  to  fix  ankles  and  wrists,  large  metal  syr- 
inge, sponges,  towels,  catheter  and  lint  for  plugging  wound  if  it  should 
be  required.  Stool  or  low  chair  for  operator.  Pocket  case ;  anjesthesia  ; 
razor  and  oil  to  shave  perineum.  Operation :  place  patient  in  Uthotomy 
position,  bandaged  or  strapped  (or  the  legs  may  be  held  in  position  by 
two  assistants).  Buttocks  to  be  well  over  end  of  table.  The  stone  should 
be  detected  whilst  the  patient  is  on  the  table,  or  else  the  operation  should 
be  postponed.  The  surgeon  sits  at  a  convenient  height,  with  his  instru- 
ments on  a  table  close  by,  and  an  assistant  to  hand  them  (the  latter  should 
be  instructed  as  to  the  size  and  kind  of  forceps  required,  etc.).  The  sur- 
geon passes  the  stafif,  and  gives  its  handle  to  an  assistant  on  the  patient's 
left.  This  assistant  keeps  the  handle  of  the  staff  perpendicular,  grasping 
it  firmly,  but  with  the  thumb  upright.  He  should  keep  the  concavity  of 
the  staff  pressed  up  against  the  symphysis  pubis.  Siu'geon  now  incises 
skin  and  fat  from  a  point  in  median  raphe  one  inch  and  a  half  in  fi'ont  of 
anus,  outward  and  backward,  to  midway  between  anus  and  tuberosity  of 
ischium.  Incision  may  be  extended  backward  in  ischio-rectal  region  if 
necessai-y.  Deepen  incision  until  the  groove  in  the  staff  can  be  felt  with 
the  tip  of  the  left  forefinger.  Using  the  same  finger  and  its  nail  as  a 
guide,  send  the  point  of  the  knife  into  the  groove  in  the  staff — of  course 
opening  the  urethra.  Next  glide  the  knife  along  the  groove  tO  it  reaches 
the  bladder.  The  passage  of  the  knife  into  the  bladder  is  recognized  by 
the  disappearance  of  the  sense  of  resistance  which  is  felt  when  the  pros- 
tate is  being  cut,  and  perhaps,  also,  by  the  escape  of  urine.'  As  the  knife 
gHdes  along  the  groove,  its  handle  should  be  depressed,  so  that  the  point 
of  the  knife  may  never  leave  the  groove  till  it  fairly  enters  the  bladder.  A 
neglect  of  this  precaution  may  result  in  the  knife  getting  between  the 
bladder  and  the  rectum.  Withdraw  the  knife,  "  lateralizing "  it  and 
deepening  the  incision  in  the  prostate  during  withdrawal.  Li  case  of  a 
large  stone,  knife  may,  during  withdrawal,  be  moved  out  of  groove  of 
staff  a  httle  to  deepen  incision.  Insinuate  left  forefinger  into  bladder, 
and,  as  soon  as  you  are  perfectly  sure  that  youi'  finger  is  in  the  bladder, 
withdraw  the  staff,  but  not  before.  Take  the  forceps  with  your  right  hand 
and  pass  them  into  bladder,  along  dorsum  of  left  index-finger.  When 
they  have  reached  bladder,  open  them,  and,  very  likely,  the  gnish  of  urine 
which  usually  now  takes  place  will  wash  the  stone  into  the  grasp  of  the 
forceps.  If  this  should  not  happen,  care  must  be  taken  in  seizing  the 
calculus  not  to  include  any  vesical  mucous  membrane,  and  the  calculus 

'  See  notice  of  Gritti's  operation,  in  Appendix. 


172  LITHOTOMY. 

should  be  so  grasped  that  its  long  diameter  may  be  in  a  line  with  the  axis 
of  the  forceps.  In  extracting  stone,  forceps  should  be  pulled  in  a  downward 
and  backward  direction,  and  with  a  twisting  movement.  When  wovmd  is 
very  deep,  blunt  gorget  may  guide  forceps  into  bladder  better  than  index- 
finger.  When  calculus  is  large,  finger  may  be  used  to  dilate  incision  of 
prostate  and  neck  of  bladder,  or  a  blunt-pointed  bistoury  may  be  used  to 
deepen  prostatic  incision.  Sometimes  stone  can  be  more  easily  extracted 
between  forefinger  and  scoop  than  by  forceps  or  by  finger  alone.  If  stone 
breaks  up,  use  of  scoop  and  of  syringe  will  be  required.  If  stone  is  very 
large,  surgeon  may  have  to  purposely  break  it  with  a  strong  hthotrite, 
and  extract  it  piecemeal.  When  the  last-mentioned  proceeding  has  to  be 
resorted  to,  the  prognosis  is  not  very  hopeful,  not  so  much  from  the  meas- 
ure itself  as  from  the  state  of  things  for  which  it  has  been  required.  The 
bladder  is  now  carefully  explored  for  another  calculus  or  for  debris.  In 
case  of  hemorrhage,  use  a  plug  made  hke  an  umbrella,  i.e.,  a  piece  of  cath- 
eter with  lint  or  linen  tied  round  it  toward  one  end.  This  end  is  passed 
into  bladder,  and  lint  or  wadding  pushed  into  the  wound  between  the  lint 
and  the  catheter.  The  whole  can  afterward  be  withdrawn  by  pulling  at  the 
lint.  Tie  the  legs  together,  and  send  patient  back  to  bed.  The  dangers 
and  accidents  of  hthotomy  are  (1)  hemorrhage,  (2)  wounding  rectum,  (3) 
missing  the  bladder  with  the  knife,  (4)  leaving  a  calculus  or  a  piece  of  cal- 
culus in  bladder,  (5)  pelvic  cellulitis,  (6)  peritonitis,  (7)  cystitis,  (8)  ery- 
sipelas, pyaemia,  and  other  accidents  common  to  wounds  in  general.  Any 
of  the  above  complications  may  be  fatal.  But  the  great  cause  of  death 
after  lithotomy  is  pre-existing  kidney  disease.  After-treatment. — Merely 
rest,  warmth,  cleanliness,  and  careful  observation.  Oil  buttocks  and 
thighs  while  \irine  continues  to  flow  through  wound. 

Median  Lithotomy. — Allarton's  form  of  the  operation  :  1,  pass  a  grooved 
staff  into  bladder  ;  2,  place  left  forefinger  in  rectum  ;  3,  feel  with  the  same 
finger  for  the  apex  of  the  prostate  ;  4,  enter  a  straight  knife  half  an  inch 
in  front  of  anus  and  direct  its  point  to  the  urethra,  just  in  front  of  apex  of 
prostate  ;  5,  with  this  knife  cut  upward  a  little,  dividing  small  portion  of 
urethra  ;  6,  pass  a  probe-pointed  director  into  the  bladder,  and  withdraw 
the  staff;  7,  gently  insinuate  finger  along  this  director  and  dilate  (or  tear?) 
prostate  with  the  finger ;  8,  extract  the  stone  with  forceps.  This  opera- 
tion is  adapted  for  extraction  of  foreign  bodies. 

Several  operators,  including  Buchanan  and  Teevan,  use  a  rectangular 
staff  when  performing  lithotomy.  At  Guy's  a  "  straight "  staff  is  used. 
N.  R.  Smith's  ingenious  apparatus  is  figured  in  Erichsen's  "  Surgery,"  ed. 
vii.,  p.  778.     For  Bilateral  and  Medio-bilateral  Lithotomy,  see  large  works. 

Supra-pubic  Lfthotomy,  or  "high"  operation. —  Instruments:  scalpel, 
artery  forceps,  dissecting  forceps,  curved  staff,  or  metal  catheter,  retrac- 
tors, lithotomy  forceps.  1.  Incise  skin  in  middle  line  from  pubes  upward, 
for  thi'ee  inches.     2.  Dissect  carefully  downward  and  backward  to  reach 


LITHOTEITY. 


173 


bladder  (which  should  contain  several  ounces  of  fluid),  pushing  away  the 
peritoneum  if  necessary,  and  keeping  near  the  back  of  the  pubes.  3.  De- 
press handle  of  staff  which  is  in  the  bladder,  so  as  to  raise  its  point ;  and 
open  bladder  by  cutting  down  on  this  point.  4.  Enlarge  incision  in  blad- 
der toward  its  neck.  5.  Extract  with  lithotomy  forceps.  Chief  dangers 
are  from  peritonitis  and  urinary  infiltration,  and  they  are  immensely  in- 
creased by  the  bad  state  of  the  kidneys,  usually  found  when  the  calculus 
is  large,  and  consequently  when  the  supra-pubic  operation  is  done.  A 
soft  catheter  should  be  left  in  the  urethra  till  the  wound  becomes  fistu- 
lous.    The  supra-pubic  operation  can  be  done  antisepticaUy. 

Lithotrity. — Operation  by  which  a  calculus  is  crushed  in  the  blad- 
der and  the  fragments  afterward  extracted  through  the  urethra.*  Circum- 
stances under  which  Suitable. — When  (1)  age  is  fifteen  or  upward,  (2)  stone 
is  less  than  one  inch  in  diameter  (if  the  other  conditions  are  favorable 
this  limit  may  be  considerably  exceeded),  (3)  it  is  of  soft  or  friable  mate- 
rial, e.g.,  phosphates,  (4)  urethra  is  healthy,  (5)  bladder  and  kidneys  are 
healthy,  (6)  prostate  is  normal.  A  combination  of  the  above  conditions 
should  make  success  certain.  Noticing  each  individually,  it  may  be  ob- 
served that  lithotomy  is  safer  when  the  age  is  under  fifteen,  when  the 
bladder  and  kidneys  are  diseased  and  the  stone  large  or  the  stones  numer- 
ous, when  the  urethra  is  narrowed  by  a  stricture  and  the  bladder  at  the 
same  time  not  very  healthy,  and  when  the  prostate  is  so  enlarged  as  to 
make  manipulation  of  the  lithotrite  or  removal  of  the  fragments  difficult. 
But  there  are  many  cases  in  which  the  reasons  for  or  against  lithotomy  or 
lithotrity  are  very  nicely  balanced.  The  main  considerations  are,  un- 
doubtedly, age  of  patient  and  health  of  genito-urinary  organs.  A  prac- 
tised lithotritist  is  justified  in  crushing  where  a  less  experienced  surgeon 
ought  to  cut.  Operation. — ^Instruments  :  Uthotrite,  Clover's  syringe,  linen 
cloth  on  which  to  wipe  lithotrite,  oil,  basin  of  water  to  receive  fragments, 
warm  water  to  inject  if  required.  Preparation. — Eest  and  treatment  of 
vesical  irritability,  if  present,  for  a  short  time  before  day  of  operation. 
Bowels  to  be  cleared.  Bladder  should  contain  four  or  five  ounces  of  urine 
or  warm  water.  Recumbent  position.  Pillow  beneath  buttocks.  Blank- 
ets to  keep  trunk  warm.  Warm  and  oil  lithotrite  and  pass  it  well  into 
bladder.  Be  extremely  gentle  throughout  sitting.  Seize  stone  by  one  of 
two  methods  :  I.  Civiale's. — In  this  the  calculus  is  picked  up  by  the  Utho- 
trite, just  as  a  bird  picks  up  a  pebble  with  its  beak.  The  following  rules 
are  usually  foUowed  :  I.  In  the  case  of  small  or  medium-sized  stone,  (1) 
pass  the  lithotrite,  closed,  to  the  back  of  the  bladder  ;  (2)  if  the  lithotrite 
has  touched  or  is  touching  the  stone,  rotate  it  slightly  away  from  the  stone 
and  withdraw  the  male  blade  ;  rotate  it  back  again  to  a  little  beyond  its 

^Professor  Dolbeau's  "perineal  lithotrity"  is  outside  the  above  definition.  His 
operation  is  really  a  combination  of  lithotrity  and  lithotomy. 


174  LITHOTRITY. 

original  vertical  position,  and  close  the  blades.  The  stone  will  probably 
be  caught ;  (3)  in  any  other  case  proceed  to  find  and  seize  the  calculus 
systematically,  thus :  1,  withdraw  the  male  blade,  then  half  rotate  (45°) 
the  hthotrite  to  the  right,  thus  /  and  close  ;  2,  withdraw  the  male  blade 
again,  then  half  rotate  to  the  left,  \,  and  close  ;  3,  rotate  (90°)  to  the  left 
horizontal,  and  close  ;  4,  rotate  to  the  right  horizontal.  In  each  case  with- 
draw male  blade  before  rotation,  and  also  depress  handle  of  Hthotrite  half 
an  inch,  so  as  to  sHghtly  tilt  up  its  blades ;  5,  6,  search  the  sides  of  the 
floor  of  the  bladder  by  a  still  further  rotation  (135°),  fii'st  to  right,  then  to 
left — before  doing  this  depress  handle  of  Hthotrite  one  inch  and  a  half ;  7, 
having  opened  the  blades,  turn  them  to  the  inverted  perpendicular  and  close, 
at  the  same  time  depressing  handle  still  farther.  In  this  way  the  Htho- 
trite searches  aU  round  its  own  axis  at  intervals  of  45°,  and  cannot  weU 
miss  anything.  Every  movement  is  to  be  conducted  with  extreme  gentleness, 
and,  in  particular,  the  centre  of  motion,  when  the  instrument  is  moved  at 
aU,  should  be  the  prostatic  part  of  the  urethra,  where  serious  results  would 
be  most  likely  to  foUow  injuiy  inflicted  by  rough  manipulation.  Small 
stones  usually  lie  toward  the  back  of  the  trigone.  IE.  In  the  case  of  a 
large  stone,  rotate  away  the  blades  to  open  them,  as  in  the  cases  previously 
noticed  ;  but  do  not  open  the  Hthotrite  by  pulling  back  the  male  blade ; 
open  it  by  pushing  forward  the  female  blade,  leaving  the  male  at  the  neck 
of  the  bladder  ;  then  rotate  toward  the  stone  and  seize.  //.  English  Mode 
of  Seizing  Stone. — The  handle  of  the  Hthotrite  is  raised  so  as  to  depress  its 
blades  against  the  base  of  the  bladder.  The  male  blade  is  then  with- 
drawn, the  handle  being  simultaneously  raised  a  Httle  more.  If  the  cal- 
culus does  not  then  fall  between  the  blades,  tap  the  Hthotrite  lightly  in 
front  or  on  one  side,  so  as  to  try  by  the  sHght  concussion  to  dislodge  the 
calculus.  This  failing,  the  blades  may  be  rotated  sHghtly,  first  to  one 
side,  and  then,  if  necessary,  to  the  other. 

The  stone  being  seized,  rotate  the  Hthotrite  a  fourth  of  a  turn  on  its 
axis  before  crushing,  so  as  to  find  if  any  mucous  membrane  has  been  ac- 
cidentally trapped.  Work  always  as  near  the  middle  of  the  bladder  as  pos- 
sible, and  always  over  the  same  spot.  On  this  spot  the  fragments  will  faU, 
and  from  it  they  can  be  picked  up  and  further  crushed,  if  necessary.  No 
sitting  should  last  more  than  five  minutes.'  If  pain  is  produced,  the  sit- 
ting should  be  cut  short.  Sometimes  one  sitting  wiU  cnish  the  stone  com- 
pletely. The  smaller  the  stone  and  the  healthier  the  bladder,  the  longer 
each  sitting  may  be  made  and  the  fewer  are  the  operations  which  wiU  be 
required.  The  first  sitting  should  be  shorter  than  the  others.  Crush  the 
calculus  by  a  series  of  short  sharp  turns  of  the  screw.  Usual  interval  be- 
tween sittings  three  or  four  days.     Throughout  the  process  keep  the  posi- 

'  This  is  the  old  rule,  now  upset  by  Bigelow's  experience  and  teachings  {see  Litho- 
lapaxy). 


LYMPHANGITIS    AND    LYMPHADENITIS.  l75 

tion  recumbent,  more  especially  in  the  interval  between  the  first  and 
second  sittings.  It  is  at  that  time  there  is  great  danger  of  impaction  of  an 
angular  fragment  in  neck  of  bladder  or  in  urethra.  When  removing  lith- 
otrite  alvfays  previously  see  that  the  male  blade  is  pushed  home,  and  that 
there  is  no  fragment  separating  it  from  the  female.  The  fragments  and 
debris  may  be  left  to  be  washed  out  by  the  urine,  or  partly  brought  away 
through  a  silver  catheter  with  a  large  eye  in  its  concavity  ;  or  they  may  be 
washed  out  by  means  of  Clover's  syringe.*  Finally,  before  pronouncing 
the  case  complete,  a  most  careful  exploration  of  the  bladder  should  be 
made  with  a  small  lithotrite,  lest  a  single  fragment  should  remain  to  form 
the  nucleus  of  a  new  stone.  The  diet  shovdd  be  rather  low,  the  drinks 
demulcent  and  copious,  the  clothing  warm.  Morphia  suppositories  may 
be  useful. 

Accidents  and  Complications  of  Lithotrity. — 1,  Impaction  of  fragments 
in  urethra  or  in  neck  of  bladder  ;  2,  retention  of  urine  ;  3,  cystitis ;  4. 
renal  irritation,  and  even  suppression  of  urine  ;  5,  orchitis  ;  6,  abscess  in 
prostate  ;  7,  inflammation  of  veins  around  neck  of  bladder  ;  8,  pyaemia ; 
ninthly,  may  be  added  effects  of  culpable  clumsiness  in  operating,  e.g.,  lac- 
eration of  the  urethra  or  bladder.  Impaction  of  fragments  in  urethra  de- 
mands instant  treatment.  If  it  occurs  near  bladder,  endeavor  to  push  back 
fragment  with  large  catheter.  If  it  is  nearer  the  meatus,  attempt  to  ex- 
tract it  with  Civiale's  urethral  scoop,  using  the  greatest  care  and  gentle- 
ness. It  may  be  necessary  to  open  the  urethra  from  without.  Retention 
of  urine  is  usually  only  temporary,  and  yields  to  warmth  and  liq.  opii. 
Cystitis  may  only  be  an  aggravation  of  a  condition  existing  before  the  op- 
eration, or  it  may  be  due  to  sharp  fragments,  or  to  the  atony  of  the  blad- 
der, which  in  old  people  may  prevent  the  expulsion  of  the  fragments.  It 
must  be  treated  on  general  principles,  one  of  which  will  be  to  remove  the 
cause.  The  application  of  this  principle  may  demand  the  use  of  the  lith- 
otomy scoop  or  of  Clover's  or  of  Bigelow's  syringe,  or  even  the  performance 
of  median  lithotomy  to  remove  the  irritating  fragments.  The  appearance 
of  unpleasant  symptoms  in  the  course  of  a  lithotrity  case  is  usually  held  to 
indicate  a  prolonged  interval  between  the  sittings.  Kenal  irritation  de- 
mands cupping  to  the  loins,  warmth,  purges,  etc. 

Lungs. — See  Chest,  Injuries  of. 

Lymphatics  and  Lymphatic  Glands. — Both  are  liable  to  inflam- 
mation, to  wounds,  to  hypertrophy,  and  to  cancer.  The  former  are  also 
subject  to  varix. 

Lymphangitis  and  Lymphadenitis. — Inflammation  of  the  lym- 
phatics and  their  glands.  Like  other  inflammations  it  may  be  acute,  sub- 
acute, or  chronic.  Most  of  the  differences  between  these  three  forms  are 
such  as  are  analogous  to  their  differences  in  inflammation  of  other  superfi- 

'  See  also  Litholapaxy. 


176  LYMPHANGITIS    AND    LYMPHADENITIS. 

cial  parts.  Causes. — Almost  always,  especially  in  the  case  of  acute  and  sub- 
acute forms,  absorption  of  inflammatory  or  septic  material  from  a  wound  or 
pustule,  or  fissure  or  sore.  According  to  Paget,  the  poison  or  irritant,  at 
all  events  in  the  instance  of  post-mortem  virus,  may  be  absorbed  through 
unbroken  skin.  Chronic  glandular  inflammation  and  enlargements  are 
scarcely  distinguishable  from  strumous  glands  on  the  one  hand,  and  fi-om 
lymphoma  on  the  other  ;  they  will,  therefore,  not  be  further  noticed  here. 
Anatomy. — Chiefly  deduced  by  analogy  from  observations  on  uterine 
lymphangitis.  Vicinity  of  lymphatics  and  glands  is  the  seat  of  hj^ertemia 
and  plastic  infiltration.  This  often  leads  in  parts  to  local  (rarely  diffuse) 
abscesses,  including  even  deposits  of  pus  in  the  lymphatics  themselves. 
The  process  usually  ceases  at  the  first  glands  on  the  upward  course  of  the 
lymphatics  affected.  The  glands  themselves  become  congested,  swollen  by 
serous  effusion,  and  crowded  to  obsti-uction  with  corpuscles.  The  main 
terminations  of  lymphangitis  are  three:  (1)  resolution,  (2)  suppuration, 
almost  always  with  satisfactory  recovery,  (3)  pyaemia,  and  then  usually 
deatL  Not  unfrequently  cases  of  dissecting  woxmd  with  lymphangitis  and 
abscesses  in  the  track  of  the  lymphatics  affected,  are  wrongly  spoken  of  as 
pyasmia.  If  such  cases  were  true  pyaemia,  recovery  in  them  would  scarcely 
be  so  frequent  as  it  is.  The  cellular  thickening  caused  by  lymphangitis 
and  adenitis  is  often  very  persistent,  and  the  small  erysipelatous  patches 
may  enlarge  vastly.  Signs. — Track  of  inflamed  lymphatics  marked  by  red 
lines,  or  red  band,  or  by  mere  thickening  and  hardening  of  the  lymphatic 
cord.  Often  oedema  in  the  neighborhood,  or  even  of  the  whole  region  or 
limb.  Pain,  tenderness,  stiffness.  In  certain  places  frequently  patches  of 
superficial  cutaneous  redness,  similar  to  (possibly  identical  with)  erysipelas. 
Where  suppiu-ation  occurs,  there  is  softening,  easily  detected  by  di-awing 
the  tip  of  the  forefinger  hghtly  over  the  part.  The  amount  of  fever  and 
gastric  distui-bance  varies  from  nil  to  the  highest  grade.  Usually  a  sud- 
den rise  of  temperature,  even  to  104-5°.  In  the  course  of  any  wound, 
rigors  or  such  a  temperature  usually  signify  local  lymphangitis.  Diag- 
nosis.— From  phlebitis.  Course  of  veins  and  of  lymphatics  not  anatomi- 
cally identical.  No  glands  on  the  veins.  Inflamed  veins  are  "  knotty." 
Prognosis. — Usually  in  all  respects  good :  but  in  the  case  of  large  opera- 
tion wounds,  compound  fractures,  and  the  hke,  signs  of  lymphangitis  re- 
quire very  prompt  attention  ;  and  there  are  certain  forms  of  blood-poison- 
ing which  first  manifest  themselves  by  lymphatic  inflammation,  and  wliich 
are  singularly  fatal.  The  fatahty  of  such  cases  is  usually  due  more  imme- 
diately to  pyaemia,  phlebitis,  thrombosis,  and  embolism  ;  while  its  remote 
cause  is  often  either  the  intense  septic  malignancy  of  the  absorbed  poison 
or  perhaps  local  anatomical  peculiarity,  e.g.,  proximity  to  cerebral  sinuses. 
Treatment. — Rest,  general  and  local ;  elevation,  fomentations,  poultices, 
pressui-e.  Pressure,  to  succeed,  should  be  very  skilfully  and  gently  ap- 
plied.   Equal  parts  of  extractum  belladonna  and  glycerine,  on  cotton- wool, 


MUSCLES,    DISEASES    OF.  177 

may  be  bandaged  upon  inflamed  glands.  Puncture  as  soon  as  softening 
is  distinct.  Mercurial  ointment,  iodine  paint,  pressure,  and  "  massage " 
(shampooing)  for  persistent  thickenings.  Attend  to  general  symptoms. 
Calomel  and  salines  often  valuable.     As  a  rule,  prefer  low  diet. 

Wounds  of  Lymphatics  almost  invariably  close  by  spontaneous  coagula- 
tion of  lymph.  Lymphatic  discharging  sinuses  are  very  rare.  Treatment. 
— Pressure. 

Varix  of  Lymphatics. — Very  rare.     Treatment. — Pressure. 

Meningocele. — A  congenital  hernia  of  the  membranes  of  the  brain. 
When  such  a  tumor  contains  brain,  it  is  termed  an  encephalocele.  Causes. 
— Probably  a  combination  of  imperfect  development  of  the  skull  wall  with 
a  tendency  to  hydrocephalus.  Signs. — A  tumor  situated  in  the  line  of  one 
of  the  sutures,  usually  in  the  median  line  and  toward  the  occijDut,  some- 
times at  the  I'oot  of  the  nose,  or  even  in  the  pharynx.  Occasionally  there 
is  a  peduncle.  Bluish,  or  color  of  natui'al  skin,  transparent,  pulsating  with 
the  brain  and  with  respiration.  Sometimes  compression  of  it  will  cause 
convulsions.  More  or  less  marked  hydrocephalus  almost  always  coinci- 
dent. Prognosis.  —  Almost  hopeless  as  to  ultimate  recovery.  A  small, 
pedtmculated  tumor  without  symptoms  of  hydrocephalus  would  give  the 
most  hope.  Diagnosis  fi'om  nsevus  or  fi*om  congenital  cysts  may  be  diffi- 
cult. "  The  diagnosis  "  of  meningoceles  and  encephaloceles  "  rests  first 
upon  their  congenital  occurrence  and  position,  at  one  of  the  membranous 
portions  of  the  fetal  head  ;  next  upon  their  fluid  nature  ;  thirdly,  upon 
their  considerable  and  decided  increase  in  volume  or  tension,  with  strong 
expiratory  efforts ;  fourthly,  upon  their  reducibility  in  part  or  entirely  ; 
and  fifthly,  upon  their  sharing  in  the  motions  of  the  brain  "  (Holmes,  in 
his  "System  of  Surgery,"  vol.  v.,  p.  968).  Treatment. — Support  carefully 
and  gently  with  a  smooth,  soft  pad  and  bandage.  Puncture  justifiable 
when  increase  is  continuous.  Injection  of  iodine  has  been  tried  with 
doubtful  success.  Annandale  ligatured  and  excised  successfully  in  a  some- 
what exceptional  case. 

Mollities,  Ossium. — See  Bone,  Diseases  of. 

Muscles,  Diseases  of. — The  chief  are :  1,  Atrophy  and  degenera- 
tion ;  2,  contractions  ;  3,  inflammation ;  4,  paralysis ;  5,  parasites  (tri- 
chiniasis)  ;  6,  syphilitic  affections  ;  7,  tumors.  Some  of  the  above  are 
pinmarily  nervous  affections,  but  they  are  mentioned  here  for  the  sake  of 
completeness. 

Muscle,  Inflammation  of. — Chiefly  occurs  as  an  extension  from  inflam- 
mation of  neighboring  parts,  or  as  a  result  of  injury,  or  of  syphilis.  Liable 
to  end  in  abscess,  which  may  be  very  troublesome,  especially  in  certain 
parts,  e.g.,  abdominal  wall.  Considerable  pain  and  constitutional  disturb- 
ance.    Treatment. — Local  rest,  poultices,  etc. 

Muscles,  Atrophy  and  Degenerations  of. — Four  chief  forms,  viz.,  1, 
simple  atrophy ;  2,  granvilar  degeneration ;  3,  fatty  degeneration ;  4, 
12 


178  MUSCLES,    DISEASES    OF. 

"  waxy  "  degeneration.  Simple  atrophy  is  the  form  which  occurs  from  dis- 
use, e.g.,  in  chronic  joint  disease.  Microscopically  there  are  abnormally 
few  sti'iated  muscle-fibres,  and  the  appearance  becomes  more  that  of  fibrous 
tissue.  Waxy  degeneration  occurs  as  a  sequel  of  continued  fevers.  All 
the  forms  of  degeneration  are  found  in  progressive  muscular  atrophy.  The 
microscope  shows  in  the  case  of  fatty  degeneration  numbers  of  fat-cells  in 
the  place  of  the  muscle-fibres,  and  in  the  case  of  waxy  degeneration  a 
"homogeneous,  colorless,  glistening  mass." 

Peogressive  Muscular  Atrophy. —  Vide  medical  works  in  which  it  is 
most  fully  treated,  e.g.,  those  of  Trousseau,  Reynolds,  Niemeyer,  Chai'cot 
("  Maladies  du  Systeme  Nerveux  "),  etc.  For  treatment  of  atrophy,  see  that 
of  Paralysis  of  Muscles. 

Muscles,  Contractions  of. — Causes. — 1,  Inflammation  of,  or  abscess  in 
the  muscle  ;  2,  disease  of  nerves  or  nerve-centres  ;  3,  reflex  irritation,  e.g., 
from  worms  (intestinal  irritation),  phimosis  (sexual  irritation) ;  4,  "antag- 
onism," i.e.,  contraction  of  one  set  of  muscles  because  its  opponents  are 
paralyzed  ;  5,  continued  relaxation  of  a  muscle,  e.g.,  the  state  of  the  flexors 
of  a  limb  which  has  long  been  kept  on  an  angular  splint.  Muscles  in  such 
a  state  tend  to  become  permanently  shortened.  Most  cases  of  paralytic 
taUpes  are  probably  caused  by  the  limb  permanently  assuming  a  certain 
position  under  the  influence  not,  as  was  formerly  supposed,  of  "  true  antag- 
onistic "  contractions,  but  of  mere  gravity ;  6,  mal-development ;  but  a 
muscle  which  has  never  been  developed  to  its  proper  length  cannot  be 
properly  termed  "  contracted."  The  diagnosis  of  the  affection  is  manifest ; 
that  of  its  cause  depends  chiefly  on  the  history.  Treatment. — In  a  few 
cases  it  is  sufficient  to  remove  the  cause,  e.g.,  to  circumcise  for  phimosis, 
or  to  give  santonin  and  scammony  for  worms.  In  mild  cases,  regular 
manipulation  by  stretching  or  continuous  mechanical  extension  may  suf- 
fice. But  usually  tenotomy  is  indicated.  See  Club-Foot.  Tenotomy 
should  be  followed  by  mechanical  extension,  either  gradual  or  immediate 
and  total. 

Muscles,  Pae.\lyses  of. — Almost  all  cases  which  the  surgeon  has  to  treat 
may  be  classified  as  :  1,  those  arising  from  injury  to  nei-ves  {see  Nerves, 
Injuries  of)  ;  2,  those  arising  from  direct  blows  on  a  muscle  ;  3,  infantile 
paralysis ;  4,  Duchenne's  disease  ;  5,  paralysis  from  disuse  ;  6,  neuromi- 
metic  or  hysterical  paralysis.  Paralyses  fi'om  direct  injury  require  rest  till 
tenderness  has  disappeared  ;  afterward,  manipulation,  rubbing,  kneading, 
and  passive  exercise. 

Infantile  Paralysis.—  Causes. — Can  sometimes,  but  rarely,  be  traced  to 
catching  cold.  Almost,  but  not  quite,  exclusively  a  disease  of  childhood, 
from  infancy  to  the  fourth  year,  inclusive.  Four  times  as  common  in 
summer  as  in  "winter  (Sinkler).  Similar,  though  perhaps  not  identical, 
paralyses  occasionally  follow  acute  diseases,  such  as  measles.  Symjjtoms. — 
Sudden  commencement,  usually  with  fever ;  sometimes  with  severe  cerebral 


MUSCLES,    DISEASES    OF.  179 

symptoms  (deafness,  delirium,  coma,  general  convulsions).  Very  rapidly 
developed,  complete  paralysis  of  certain  parts,  with  entire  relaxation  of 
the  affected  muscles.  Parts  affected,  variable.  Generally  lower  limbs. 
Sometimes  one  or  both  arms,  or  separate  muscles,  e.g.,  deltoid.  Serratus 
magnus  sometimes  affected  (Lees,  "  Clinical  Society  Transactions,"  1879). 
The  muscles  atrophy,  the  development  of  the  bones  is  retarded,  and,  the 
local  circulation  stagnating,  the  limbs  become  cyanotic.  But  the  general 
health  and  nutrition  remain  vigorous,  and  there  is  no  affection  of  the 
sphincters,  nor  any  considerable  disturbance  of  sensation.  In  the  course 
of  time  deformities  result,  e.g.,  talipes,  contracted  hip,  etc.  Pathology. — 
Essentially  an  inflammation  of  the  anterior  horns  of  the  gray  matter  of  the 
spinal  cord,  especially  in  the  lumbar  and  cervical  enlargements.  Prog- 
nosis.—lAitle  or  no  danger  to  life  or  general  health,  except  indirectly  from 
the  crippHng.  But  little  hope  of  important  benefit  from  treatment,  except 
orthop;tidic.  Treatment.— In  early  stages,  treat  the  main  affection  vigor- 
ously (of  course,  not  forgetting  patient's  tender  age).  Strips  of  bhster 
along  spine,  near  cervical  enlargement  in  case  of  paralysis  of  upper  ex- 
tremities, near  lumbar  when  legs  are  affected.  Cathartics.  Ergotine,  bel- 
ladonna, or  pot.  iod.  internally.  Prone  position,  if  possible.  Cold  affusion 
for  severe  head  symptoms.  Later  on,  galvanism.  Constant  current  to  spine 
itseK.  Large  electrodes,  one  to  cervical  or  lumbar  enlargement,  other  to 
anterior  surface  of  trimk.  Alternate  place  of  anode  and  cathode  every  two 
minutes.  Persevere  at  intervals  for  years  (Erb).  Faradic  electricity  to 
affected  muscles.  Anode  to  spine  or  nerve-trunks  ;  cathode  to  muscles. 
Fresh  au*,  good  diet,  cod-liver  oU,  warm  clothing  to  limbs.  Massage,  fric- 
tion, "beating,"  sea-baths.  Orthopaedic  treatment  and  appliances.  To 
prevent  the  necessity  for  these,  keep  the  paralyzed  limb  in  a  good  posi- 
tion when  at  rest.  Paralytic  deformities  are  mainly  caused  by  action  of 
gravity,  but  partially  perhaps  by  antagonistic  contraction  of  the  stronger 
muscles. 

Duchenne's  Disease,  or  Pseudo-Hypeeteophic  Paealtsis. — Cause  unknown. 
Age,  childhood.  Three  stages :  (1)  of  weakness  of  muscles  of  lower  limbs  ; 
(2)  of  gradual  hypertrophy  of,  successively,  gastrocnemii,  glutei,  and  lum- 
bar muscles,  weakness  still  persisting  ;  (3)  of  wasting  and  increased  paraly- 
sis. The  muscular  enlargement  is  due  to  growth  of  connective  tissue 
and  fat.  Idiocy  often  coexistent.  Prognosis. — Bad.  Quite  hopeless  in  third 
stage.     Treatment. — Electricity;  manipulation;  "shampooing." 

Paealysis  feom  Disuse  is  practically  identical  with  atrophy,  and  requires 
shampooing,  passive  or  active  exercise,  and  perhaps  stimulus  of  electricity. 

Hysteeicai,  Paealysis. —  Vide  Hysteeia. 

Muscles,  Tumoes  of. — Almost  any  variety  may  occur.  Sarcomata  prob- 
ably most  common.  Ossifications  of  muscles  themselves  present  appear- 
ance of  hard  tumors.  Such  ossifications  sometimes  affect  the  adductors  of 
cavalry  soldiers  ("rider's  bones").    Cysts.    Cancer.    The  Trichina  spiralis, 


180  NECK,    INJURIES    OF. 

a  nematoid  worm,  is  a  parasite  whicli  lies  encysted  in  the  muscles  of  pa- 
tients affected  with  "  Trichiniasis,"  as  the  affection  is  termed. 

Muscles  and  Tendons,  Euptuke  of. — Tendo  Achillis  and  quadriceps  ex- 
tensor of  thigh  most  often  affected.  Occm-s  chiefly  in  middle  age.  Treat- 
ment.— Fix  in  a  relaxed  position  for  a  fortnight.  Kesume  use  cautiously 
and  gradually. 

Naevus. —  Vide  Ttjmors,  Vascular.     (Angiomata.) 

Nails. — Chief  Affections. — Ingrowth,  onychia,  hypei-trophy,  and  psori- 
asis. 

Nail,  Ingrown  Toe,  is  really  the  overgrowth  of  the  flesh  at  the  side  of 
the  nail,  caused  by  pressure  of  boot  and  by  not  cutting  the  nail  square. 
Treatment. — Bad  cases  require  perfect  rest.  With  the  point  of  a  penknife 
insinuate  a  little  cotton-wool  beneath  the  side  of  the  nail  and  between  the 
edge  of  the  nail  and  the  overlapping  flesh.  Avoid  cutting  the  nail.  Poul- 
tice and  rest  thoroughly  if  there  is  much  inflammation.  In  a  few  cases 
avulsion  of  the  whole  nail  (of  course,  under  either  local  or  general  anaes- 
thesia) may  be  necessary. 

Onychl^. — An  ulceration  of  the  matrix  of  a  nail.  Varies  much  in  sever- 
ity. The  worst  cases  are  termed  "  Onychia  maligna."  Causes. — Bad  con- 
stitution ;  weakly  children  especially  liable  ;  local  injury,  neglect,  syphilis. 
Signs. — Ulceration  sometimes  confined  to  one  angle  of  the  matrix,  some- 
times extending  along  both  sides  and  base  of  matrix.  Nail  blackens, 
loosens,  and  peels  off,  perhaps  in  strips.  Sanious,  foul  discharge.  Often 
great  pain.  Treatment.— RemoYe  nail.  Cari-y  hand  in  a  sling  beneath 
chin  ;  poultice  a  day  or  two  ;  then  dress  with  ung.  hyd.  oxid.  rubri,  or 
carbohc  oil.  Nitrate  of  lead.  Ung.  iodoformi  would  be  worth  trying  when 
inflammation  is  reduced.  ^.  Liq.  ai-senicalis,  3  iij-,  aquse  ad.  3  ij.  M.  Ft. 
lotio.     Black  wash.     Internally  give  tonics  and  cod-liver  oil. 

Hypertrophied  Nails  should  be  removed,  and  measures  be  taken  to 
protect  against  local  irritation. 

Psoriasis  of  the  Nails. — "  The  central  part  of  the  naU  becomes  thick- 
ened, rough,  and  scabrous,  and  unnaturally  convex  ;  the  free  edge  is  often 
split ;  the  cuticular  fringe  at  the  bottom  of  the  nail  is  ragged  and  re- 
tracted, leaving  a  deep  fissure  between  the  nail  and  the  skin  of  the  finger. 
The  whole  nail,  in  an  extreme  case,  resembles  the  outside  of  the  concave 
shell  of  an  oyster"  (T.  Smith).  Treatment. — Smooth  down  with  sand- 
paper. Dress  at  the  margin  mth  equal  parts  of  ung.  picis  liq.  and  ung. 
hydrarg.  ammon.  Constitutionally  give  arsenic  or  antisyphilitics,  as  may 
be  indicated.  Remember  that  parasitic  disease  of  the  nails — "ring- 
worm " — occurs,  but  with  extreme  rarity.  May  be  detected  by  the  micro- 
scope. 

Neck,  Injuries  of. — See  Sprain  ;  Throat,  Cut  ;  Spine,  Dislocations 
OF,  etc. 

Neck,  Congenital  Fistuije  in,  called  "  Branchial  Fistulae,"  because  they 


NERVES,    INFLAMMATION    OF.  181 

are  probably   due  to  incomplete  clostu-e  of  the  brancliial  clefts.     Very 
small ;  usually  give  exit  to  a  serous  discharge. 

Neck,  Tumors  op,  are  usually  enlarged  glands,  or  abscesses  resulting 
therefrom.  More  rarely,  adenomata,  cysts,  "hydroceles,"  aneurisms,  or 
cancers.  See  also  Beonchocele.  Lipomata  not  uncommon  at  back  of 
neck. 

Neck,  Hydrocele  of. — A  cystic  tumor,  usually  situated  at  the  base  of 
the  posterior  triangle.  Contents. — Yellow  or  brown  serous  fluid.  Diagno- 
sis.— By  fluctuation  and  transparency.  Treatment. — Tap  and  inject  with 
iodine. 

Wry-Neck. — Depends  on  contraction  of  the  stemomastoid.  (Besides 
true  wry-neck,  there  are  hysterical  wry-neck  and  a  spurious  wry-neck, 
caused  by  caries  of  the  cervical  vertebrae.)  Causes. —  Fide  Muscles,  Con- 
traction OF.  Symptoms. — Distance  from  ear  to  sternoclavicular  articula- 
tion, shortened  on  side  of  contracted  stemomastoid.  Head  bent  over  to- 
ward, and  face  turned  away  from  same  side  ;  head  also  bent  downward. 
Contracted  stemomastoid  feels  tense,  especially  when  an  attempt  is  made 
to  raise  head.  Lateral  curvature  of  spine  frequently  a  secondary  result. 
Arrested  development  of  face  on  affected  side.  Other  muscles  besides 
stemomastoid  sometimes  contracted,  but  not  so  firmly.  Treatment. — 
Divide  stemomastoid  subcutaneously,  and  afterward  fix  the  head  straight 
or  slightly  inclined  toward  opposite  side  by  a  special  machine,  or  by 
strapping  and  bandages.  A  leather  collar  sometimes  useful  in  mild  cases. 
Division  of  Stemomastoid. — Divide  close  to  oiigin.  Divide  sternal  and 
clavicular  heads  separately.  Turn  edge  of  knife  toward  skin,  first  passing 
blade  beneath  muscle.  Do  not  insert  knife  too  deeply,  as  death  has  oc- 
curred several  times  from  wounds  of  important  vessels.  After-treatment 
must  be  persevered  in  for  a  month  or  two.  Manipulation  suffices  toward 
the  latter  part  of  the  time.  For  hysterical  wry  neck,  division  of  stemo- 
mastoid is  generally  rather  prejudicial  than  useful.  Treat  on  the  princi- 
ples laid  down  for  Hysteria,  q.  v.  In  wry -neck  from  spiaal  caries,  treat 
the  prime  disease. 

Nerves,  Inflammation  of. — (1)  Acute,  (2)  chronic.  Acute  neuritis 
is  uncommon,  and  is  marked  by  continuous  pain,  tenderness,  and  swelling 
along  the  course  of  the  affected  nerve,  and  often  by  spasms  of  the  muscles 
connected  with  it. 

Chronic  Neuritis — Causes. — Exposure  to  cold  and  damp  ;  the  same 
causes  combined  with  injury,  injury  alone,  excessive  fatigue,  rheumatic 
constitution.  Symptoms. — Sometimes  like  those  of  acute  neuritis,  but 
milder  and  more  persistent.  After  death  the  nerve  is  found  swollen,  in- 
jected, and  occasionally  suppurating.  Treatment. — General  and  local  an- 
tiphlogistics  ;  rest ;  position  of  relaxation  ;  leeching ;  purgation  ;  iodide  of 
potassium.  Specific  remedies  when  rheumatism,  gout,  or  syphilis  is  diag- 
nosed. 


182  NOMA. 

Neeves,  Tumors  of. — See  Tumors,  Neuroma. 

Neuralgia. — Pain  in  the  course  of  a  nerve,  and  not  caused  by  any 
visible  disease  or  injury  to  the  parts  supplied  by  that  nerve.  Causes. — 
(1)  Obscure  injury  to  the  nerve  ;  (2)  foreign  body  irritating  it ;  (3)  tumors 
pressing  on  it ;  (4)  compression  by  contracted  cicatrices  ;  (5)  overfiUing  of 
veins  near  nerves  as  they  pass  through  long  canals,  e.g.,  infra-orbital 
canal;'  (6)  poisons  in  the  blood,  e.g.,  malaria,  mercury,  lead,  copper,  etc.; 
(7)  neuralgia  appears  to  be  sometimes  reflex,  and  to  be  caused  by  irrita- 
tion of  some  other  nerve  than  that  affected.  Lastly,  in  an  immense  num- 
ber of  cases,  the  cause  is  quite  unknown.  The  exciting  cause  of  a  neuralgia 
is  frequently  catching  cold,  or  exercising  the  part  subject  to  the  com- 
plaint. Pathology. — When  any  distinct  anatomical  change  is  found,  the  af- 
fection is  no  longer  called  a  neuralgia,  but  a  "  neuritis,"  or  whatever  may 
be  the  nature  of  the  change  observed.  During  a  neuralgic  paroxysm, 
there  is  generally  local  hypersemia.  Symptoms  and  Course. — Extremely 
various.  Continuous  or  remittent  or  intermittent,  short  or  enduring,  cir- 
cumscribed or  diffuse,  lancinating,  aching,  or  burning.  Often  reheved, 
sometimes  aggravated  bypressui-e.  Tender  spots  occasionally  found,  e.g., 
where  lateral  intercostal  cutaneous  nerves  pierce  the  external  intercostal 
muscles  in  neuralgia  of  breast.  Years  sometimes  do  not  suffice  to  remove 
obstinate  neuralgia.  Treatment. — Treat  cause.  Iron  in  anaemia.  Quinine 
in  remittent  cases.  Anti-rheumatics  in  rheumatic  cases.  Locally  :  linimen- 
tum  aconiti  ;  linimentum  beUadonnse  ;  empl.  belladonna  ;  tinct.  capsici  ; 
chloroform  ;  chloroform  saturated  with  iodoform  ;  blisters  ;  ether  spray  ; 
hot  fomentations  ;  ice  ;  ung.  veratriae.  Electricity,  faradization  ;  con- 
stant current.  Also  excision  of  nerves  and  nerve-ganglia.  Internally. — 
(Besides  iron,  quinine,  etc.,  mentioned  above)  chloride  of  ammonium  in 
half -drachm  doses  ;  phosphonis  ;  croton-chloral  (gr.  v.  every  three  hours)  ; 
chloral;  gelseminum ;  chloroform;  "tonga,"  in  3j.  doses,  three  times  a 
day  ;  stomachics  ;  tonics,  etc.  Vide  works  on  "  Therapeutics  ; "  change  of 
air  and  scene ;  hydropathy  ;  colchicum  in  gouty  subjects.  Sometimes 
moi-phia  subcutaneously  seems  to  be  the  only  resource.  But  such  injec- 
tions are  contraindicated  in  cases  of  great  debility,  in  advanced  age,  in 
cerebral  hypersemia,  and  in  organic  disease  of  the  heart  (Erb). 

Nipple,  Sore. — Solid  nitrate  of  silver  to  any  fissure.  Ung.  hyd.  nit. 
No  soaj),  merely  hot  water  in  washing.  Lotions  of  zinci  sulph.  or  borax. 
Leaden  shields.     Cure  any  aphtha  of  child's  mouth. 

Nipples,  Retracted. — When  merely  a  natural  conformation,  attempt 
to  bring  out  by  repeatedly  drawing  with  the  breast-pump. 

Noma.  — 6'ee  Cancrum  Oris,  Disease  attacks  external  genitals  of  fe- 
male children  as  well  as  mouth. 

'  Henle,  quoted  by  Niemeyer. 


NOSE,    DISEASES    OF.  18o 

Nose,  Diseases  of.— Those  which  require  special  notice  are  acne 
rosacea,  lipoma,  lupus,  epithelioma,  chronic  nasal  catarrh,  ozena,  syphilis, 
tumors  (including  polypi),  and  deformities. 

■  Acne  Rosacea. — Occurs  chiefly  in  young  women,  in  women  of  50,  and 
in  men  advanced  in  life.  Causes. — Indigestion.  Disorders  of  sexual 
system.  Local  irritation,  e.g.,  from  exposure  to  sun  and  weather.  When 
attacking  old  men  the  cause  is  usually  spirit-drinking.  Pathology. — Cuta- 
neous hypertrophy  and  capillary  congestion.  Sebaceous  glands  not  neces- 
sarily affected.  Treatment. — Remove  the  cause  if  possible.  Regulate  the 
habits.  Treat  indigestion.  Locally. — Ung.  sulphuris  iodidi.  Lotio  hy- 
drarg.  perchlor.  (gr.  ij.  to  I  ].).  Bathing  with  water  as  hot  as  it  can  be  borne. 
Abstinence  from  stimulants.  Riding  and  driving  exercise.  The  dilated 
capillaries  may  be  sHt  up  and  touched  with  liq.  ferri  perchlor. 

Nose,  Lipoma  of. — Integumentary  and  subcutaneous  hypertrophy  of 
ahe  and  tip  of  nose.  Variable  in  extent  and  size.  Attacks  old  men.  Fibro- 
cellular  and  not  fatty  in  structure.  Treatment. —B,emoYahlG  by  suitable 
incisions.     Slight  danger  of  erysipelas. 

Nose,  Lupus  of. — VideLtvPVS. 

Nose,  Epithelioma  of.— See  Cancer. 

Nasal  Cataerh,  Chronic.  —  Causes. — Residence  in  damp,  cold  localities, 
repeated  acute  catarrhs,  constitutional  predisposition,  struma,  exposure  to 
draughts,  irritating  dust,  in-itation  of  nasal  polypi  (and  specific  causes— see 
"  Ozsena  ").  Signs. — Mucous  membrane  swollen,  red,  covered  with  secretion, 
mucous  or  muco-purulent,  moist  or  crusted.  Sometimes  a  nasal  tone  of 
voice.  Nose  may  be  occluded  by  swelling  of  mucous  membrane.  Pharynx 
usually  also  affected.  Treatment. — Treat  the  cause.  Nasal  douche  with 
solutions  of  chlorate  of  potash,  common  salt,  phosphate  of  soda,  and  car- 
bonate of  soda,  in  hot  water  (hot  water  is  preferable  to  lukewarm).  Use 
douche  twice  a  day.  Solutions  should  be  just  strong  enough  to  taste 
saline.  Later  on,  astringents  should  be  added  in  small  quantities  to  the 
saline  washes.  Nose  not  to  be  blown  for  a  short  time  after  douching.  The 
same  fluids  may  be  applied  with  an  atomizer  instead  of  the  douche.  In- 
halation of  vapor  of  chloride  of  ammonium.  Insufilation  of  powdered 
alum,  bismuth,  and  starch,  etc.  Iodoform  powder  sniffed  up.  Iodoform 
in  vaseline  (gr.  xx.  to  5  j.)  :  applied  with  a  small  brush  far  up  each  nostril 
(Lennox  Browne  and  Brandeis).  With  regard  to  the  douche,  it  should  be 
noted  that  Professor  Roosa  of  New  York  strongly  condemns  it  as  too 
dangerous  to  the  ears  ;  and  even  Professor  CasseUs,  who  stoutly  defends  it, 
never  trusts  patient  to  use  it  himself.  Sleep  with  a  high  pillow.  Moderate 
diet.  Fish  and  milk.  Avoid  stimulants.  Cod-liver  oil  at  night  some- 
times beneficial.  Change  of  air. ^ and  scene.  Dry,  elevated  regions.  In- 
ternally, large  doses  of  chlorate  of  potash. 

OzMSk. — An  habitual  and  offensive  odor  from  the  nose,  often  amount- 
ing to  a  horrid  stench,  and  almost  always  of  a  certain  characteristic  nature. 


184  NOSE,    DISEASES    OF. 

Causes. — (1)  Strumous  ulceration,  (2)  syphilitic  ulceration,  (3)  necrosis 
from  non-specific  causes,  (4)  long-continued  chronic  catari'h,  (5)  foreign 
bodies  impacted,  (6)  merely  a  peculiar  tendency  to  decomposition  of  the 
nasal  secretion.  Seat  of  Disease. — Any  part  of  nasal  walls,  or  of  sinuses 
opening  into  nose.  Amount  of  discharge  very  variable.  Often  all  passes 
backward  into  pharynx.  Prognosis. — Unless  cause  can  be  detected 
and  easUy  removed,  ozsena  is  very  difficult  to  cure.  May  last  for  years. 
"When  complicated  with  bone  disease,  deformity  a  frequent  result.  Treat- 
ment.— Antisyphilitics  for  syphilis.  Cod-liver  oil,  ii'on,  arsenic,  etc.,  for 
struma.  Explore  nasal  cavity  carefully  with  a  strong  light,  a  mirror,  and 
speculum.  Kemove  dead  bone.  Nasal  douche  with  hot  alkaline  or  sahno- 
astringent  solutions  (see  Nasal  Cataeeh).  Solutions  of  Condy's  fluid. 
Insufflation  of  mercurial  powders — white  or  red  precipitate,  2  grains  to  1 
drachm  of  sugar.  Iodoform  {see  Nasal  Catakrh).  Pugin  Thornton 
strongly  recommends  spray  of  solution  of  borate  and  carbonate  of  soda.' 
In  syphilitic  ozEena  of  infants,  syringe  out  nostrils  with  hot  saline  solutions, 
and  afterwai'd  insert  melted  ung.  hyd.  nitrat.  dil.,  or  iodoform  ointment. 
Of  course  remove  foreign  bodies.  Treatment  of  ozsena  must  be  perse- 
vering, and  used  twice  or  even  three  times  a  day. 

Nose,  Tumors  of,  are  either  (1)  "mucous  polypi,"  (2)  "fibrous  polypi," 
(3)  malignant,  (4)  cartilaginous,  or  (5)  osseous.  The  first  three  are  the 
most  common,  especially  the  first.  Causes. — As  obscure  as  those  of 
tumors  elsewhere  ;  but  mucous  polypi  sometimes  appear  to  arise  from 
long-existing  chronic  catarrh.  Symptoms  and  Diagnosis. — Those  of  nasal 
or  nasopharyngeal  obstruction,  often  combined  with  nasal  catarrh  and 
leading  to  deformity  of  the  face.  Mucous  polypi  may  usually  be  seen  and 
recognized  by  their  pale,  semi-transparent  appearance  and  soft  consist- 
ence. Fibrous  polypi  cause  hemorrhages,  are  red  and  firm,  are  usually 
single,  and  are  attached  to  the  roof  of  the  nasopharyngeal  cavity.  Malig- 
nant tumors  gi'ow  rapidly,  bleed,  fungate,  infiltrate  neighboring  parts, 
cause  pain  (often  considerable),  and  cachexia.  Cartilaginous  and  osseous 
tumors  are  rare,  and  may  be  known  by  their  consistence.  Very  rarely 
certain  extraordinary  loose  osseous  tumors  are  found  in  the  nose  or  the 
adjoining  sinuses.  Pathology. — Mucous  polypi  are  fibrocellular  tumors, 
or  myxomata,  or  fibromyxomata.  Fibrous  polypi  are  fibrosarcomata  or 
pure  sarcomata.  Mucous  polypi  are  usually  attached  to  the  outer  side  of 
the  nasal  cavity,  especially  to  the  middle  turbinated  bone.  Fibrous  polypi 
spring  from  the  periosteum.  They  are  usually  attached  toward  the  back 
of  the  roof  of  the  nose.  See  Cancer,  for  the  structure  of  cancerous 
tumors.  Treatment. — Twist  and  tear  out  mucous  polypi  with  polypus 
forceps.     Ordinary  dressing  forceps   do   not  usually   bite  weU   enough. 

'  B  •  Sodse  carb.,  Bodae  biborat,  a5  3  ij. ;  liq.  sodae  chlorinataa,  3  ss.  to  3  ij. ;  glycerini, 
l\.;  aq.  ad.  §  viii. 


(ESOPHAGUS,    STEICTURE    OF.  185 

Afterward,  to  prevent  or  delay  recurrence,  prescribe  tannin  as  snuff,  or 
else  spray  of  solution  of  sulphurous  acid.  A.  sulphurosi  (P.B.),  j.  to  aquge 
iij.  Polypus  snare.  Nasopharyngeal  polypi.  Fibrous  polypi,  if  they  can- 
not be  snared,  may  require  operations  even  of  the  first  magnitude,  e.g., 
removal  of  superior  maxillary  bone.  Other  procedures  involve  cutting 
through  hard  and  soft  palate,  or  slitting  up  nose  close  to  middle  line,  or 
Langenbeck's  operation,  which  resembles  excision  of  upper  jaw,  only  that 
bone,  after  being  turned  out,  is  replaced.  Cancer  requu'es  excising  like 
fibrous  polypus,  unless  too  far  advanced. 

Abscess  is  an  occasional  cause  of  swelling  in  the  nose,  especially  during 
syphiUtic  disease.     Open  early. 

Nose,  Deformities  of. — Congenital  are  very  rare.  Flattening  from 
syphilis  or  from  accident  is  difficult  to  treat,  especially  the  former.  To 
raise  a  nose  depressed  by  fracture,  instruments  such  as  those  of  S.  Gamgee 
may  prove  useful. 

CEsophagus,  Foreign  Bodies  in. — May  lodge  in  any  part,  but  usu- 
ally stop  at  commencement  just  behind  cricoid  cartilage.  Symptoms. — 
Local  pain,  especially  on  attempting  to  swallow.  The  character  of  the  pain 
and  the  presence  or  absence  of  dyspnoea  depend  on  the  nature  and  size  of 
the  body.  So  also  do  the  prognosis  and  treatment.  A  soft,  soluble,  or 
macerable  substance  may  pass  eventually  with  little  or  no  external  assist- 
ance, or  may  easily  slip  down  before  the  probang.  A  pin  may  be  caught 
by  the  horse-hair  probang,  and  a  coin  by  the  "  coin-probang,"  or  either 
may  be  brought  up  by  forceps,  such  as  those  of  Bryant.  But  large 
jagged  bodies  may  demand  a  cutting  operation  ;  and,  when  they  cannot 
be  recovered  by  less  serious  means,  cesophagotomy  had  better  not  be  de- 
layed. Urgent  dyspnoea  may  demand  laryngotomy  or  tracheotomy.  Oil 
the  probangs  and  oesophageal  bougies  before  using  them.  The  fingers 
are  useful,  not  only  for  examining  the  pharynx,  but  for  hooking  out  for- 
eign bodies  from  its  lower  end.  If  the  foreign  body  reach  the  stomach, 
keep  the  patient  in  bed,  and  give  large  quantities  of  bulky  food,  but  no 
drugs. 

CEsoPHAGOTOMT. — Scalpels,  forceps  (dissecting  and  artery),  retractors, 
director,  probe,  oesophageal  forceps,  or  some  other  long  curved  instrument 
to  act  as  a  staff  passed  down  the  oesophagus.  Place  a  pillow  beneath 
shoulders.  Incision  for  five  inches  along  anterior  border  of  stemomastoid 
(left,  unless  foreign  body  project  to  right),  with  its  centre  opposite  position 
of  foreign  body.  Proceed  as  in  tying  carotid  ;  but  instead  of  opening 
carotid  sheath,  retract  it  and  its  contents  outward.  Retract  larynx  the 
other  way.  In  opening  oesophagus,  take  care  not  to  wound  recurrent 
laryngeal  nerve.  Feed  for  a  few  days  through  an  oesophageal  tube  passed 
through  mouth  and  beyond  wound.     Prognosis  very  good. 

CEsophagus,  Stricture  of. — Forms :  1,  cicatricial  after  injury ;  2,  idio- 
pathic fibrous  thickening  ;  3,  syphilitic  ulceration  ;  4,  cancer ;  5,  pressure 


186  PALATE. 

of  neighboring  tumors.  No.  2  is  very  uncommon ;  No.  4  is,  unfortu- 
nately, not  so.  The  most  usual  form  of  tumor  to  compress  the  oesopha- 
gus is  a  thoracic  aneiu-ism.  Signs. — The  essential  one  is  dysphagia — diffi- 
culty of  swallowing.  This  may  come  on  so  gradually  as  to  be  unperceived 
until  the  power  of  swallowing  anything  but  the  smallest  morsels  has  been 
lost.  More  or  less  pain.  Progressive  emaciation.  The  most  terrible 
symptom  to  the  patient  is  the  feeling  of  unappeased  hunger.  Ulceration 
is  indicated  often  by  fetor  of  the  breath,  or  by  the  presence  of  blood  on  a 
bougie  passed  gently.  To  diagnose  the  nature  of  the  stricture,  whether 
cancerous  or  syphilitic  or  simple,  consider  the  age,  histoiy,  and  collateral 
symptoms  of  the  patient— e.  g.,  a  tumor  may  be  felt  at  the  root  of  the  neck, 
or  cancerous  glands  may  be  found  in  the  neck,  or  examination  of  the  chest 
may  discover  indubitable  symptoms  of  aneurism,  and  so  on.  The  patient's 
feelings  are  deceptive  as  to  the  locality  of  the  strictiire,  he  usually  referring 
it  to  beneath  the  manubrium  sterni.  Prognosis. — In  many  cases,  death  from 
starvation,  sometimes  from  hemorrhage  or  the  spread  of  cancer.  Difficult 
to  treat  even  a  fibrous  stricture  successfully  with  bougies.  Great  gentleness, 
tact,  patience,  and  perseverance  may  succeed.  Whenever  the  cause  can  be 
removed,  the  prognosis  is  good,  unless  there  be  a  severe  ulceration,  likely 
to  be  followed  by  cicatricial  contraction.  Treatment. — First  examine  with  a 
well-oiled  bougie.  If  one  can  be  passed  gently,  try  to  gradually  dilate,  by 
passing  from  day  to  day  increasing  sizes,  unless  the  cause  be  manifestly  pres- 
sure fi'om  without,  e.g.,  aneurismal.  If  the  cause  be  clear,  of  coui-se  treat  it 
In  case  of  doubt,  iodide  of  potassium  and  rest  are  generally  worth  a  good 
trial.  Excision  of  cancer  of  the  oesophagus  has  hitherto  been  unsuccessful ; 
and  gastrotomy  {quod  vide)  has  had  discouraging  results  (two  successes  to 
many  failures),  perhaps  partly  because  it  is  mostly  postponed  till  too  late. 
Life  can  be  prolonged  by  nutrient  enemata  when  swallowing  has  become 
impossible. 

Orbit. — An  enlargement  here  may  be  aneurism  [quod  vide),  or  abscess, 
or  enlargement  of  lachrymal  gland,  or  exostosis,  or  hydatids,  or  cancerous 
or  other  tumor. 

Ozasna. —  Vide  Diseases  of  Nose. 

Palate. — Cleft  Palate. — A  congenital  deformity,  due  to  non-union  of 
palate  plates  of  palate  bones  and  superior  maxillaries  with  their  fellows,  or 
of  the  superior  maxillaries  with  the  premaxiUaries,  or  to  non-union  of 
the  two  halves  of  the  soft  palate.  The  amount  of  imperfection  varies 
from  merely  bifid  uvula  to  a  complete  chasm  from  pharynx  to  face.  Often 
complicated  with  hare-lip.  The  parts  affected  are  more  or  less  stunted  in 
growth  :  hence  width  of  cleft  varies.  Treatment. — An  infant  with  cleft 
palate  cannot  suck  :  hence  it  requires  hand-feeding.  But  it  should  be 
hand-fed  with  its  mother's  milk  only  for  the  first  two  months.  Upon  all 
cases,  except  a  few  in  which  the  cleft  is  too  wide,  a  plastic  operation  must 
be  done.     If  possible,  operate  before  the  chUd  has  begun  to  talk.     When 


PALATE.  187 

the  cleft  is  hopelessly  wide,  let  a  dentist  fit  the  mouth  with  an  "  obtura- 
tor "  of  gold  or  vulcanized  rubber. 

Staphylorraj^hy  (for  cleft  of  soft  palate). — Essential  steps  of  the  opera- 
tion are  three,  viz.,  (1)  paring  edges  of  cleft,  (2)  uniting  them  by  sutures, 
(3)  incising  to  relieve  tension.  Chloroform  children.  Anaesthesia  optional 
in  case  of  adults.  Insert  Smith's  gag.  (It  is  as  well  to  see  that  this  gag  fits 
on  the  day  before  the  operation.)  The  edges  are  pared  by  means  of  long 
forceps  and  long-handled  knife.  Avoid  unnecessary  and  rough  spong- 
ing, as  it  increases  flow  of  sahva.  Sutures  are  of  horse-hair,  catgut,  silk 
and  silver  wire.  Their  strength  is  in  the  inverse  order  in  which  they  are 
named  here.  The  ends  of  silver  wire  may  irritate  the  tongue.  Alternate 
sutures  of  horse-hair  and  silk  answer  weU.  The  sutures  are  passed  by 
long-handled  and  curved  needles.  Startin's  needle.  Plan  of  passing 
thread  through  one  flap,  then  through  loop  of  a  thread  ah'eady  passed 
through  other  flap,  and  lastly  dragging  it  completely  through  by  means  of 
this  loop.  There  is  a  simple  little  instrument  for  twisting  wire  sutures. 
Pass  most  of  the  sutures  before  tying  one.  Check  bleeding  before  tying. 
Bleeding  rarely  troublesome.  Iced  water,  gentle  pressure  with  small 
sponge,  and  waiting  a  minute  or  two,  sufl&ce  to  check  it.  The  accessory 
incisions  to  reheve  tension  may  be  done  (1)  a  few  days  before  the  opera- 
tion, as  suggested  by  Callender,  or  (2)  just  before  the  operation,  or  (3) 
just  after  the  operation.  They  are  either  (1)  simply  lateral  cuts  parallel 
to  the  cleft  and  close  to  alveoH,  or  (2)  more  scientifically  planned  pro- 
ceedings to  divide  levator  palati  and  palatopharyngei.  Palatopharyngei 
divided  by  merely  snipping  across  posterior  pillars  of  fauces.  Two  ways 
of  dividing  levator  palati,  viz.,  Fergusson's  and  Pollock's.  Few  people 
competent  to  perform  either  with  certainty  after  merely  reading  a  verbal 
description  ;  while  any  one  can  do  either  after  half  a  minute's  practical 
illustration.  Fergusson  divided  the  perpendicular  part  of  the  levator  pal- 
ati midway  between  the  Eustachian  tube  (its  orgin)  and  the  hamular  pro- 
cess, where  it  bends  into  the  palate.  Pollock  divides  the  horizontal  part 
of  the  levator  palati  as  it  lies  in  the  soft  palate.  Fergusson  used  a  rectan- 
gular knife,  which  he  passed  through  the  cleft  in  the  palate.  Pollock  uses 
a  straight  knife  which  he  passes  through  the  soft  palate  close  to  the  hamu- 
lar process  (which  can  be  felt  with  the  finger).  "If  the  palate  will  not 
come  easily  together,  two  lateral  oblique  cuts  may  be  made,  one  on  either 
side,  above  the  highest  sutui'e,  separating  the  soft  from  the  margin  of  the 
hard  palate  to  a  small  extent"  (T.  Smith). 

Hard  Palate,  Opeeatiox  fob  Cleft  of. — Resembles,  in  principle,  that  for 
cleft  of  soft  palate.  Mucous  membrane  and  subjacent  periosteum  are 
scraped  from  lower  surface  of  palate  plates.  Incisions  are  made  along 
alveolar  border  of  palate,  and  the  edges  of  the  cleft  pared.  Then  the 
loose  dependent  flaps  are  brought  together  in  the  middle  line,  and  united 
by  strong  sutures.      Beware   of   "buttonholing"  the  flaps   in   scraping 


188  PARACENTESIS  THORACIS. 

them.  Various  forms  of  raspatories  may  be  used.  In  sepai'ating  the  flap 
from  the  bones,  work  from  without  inward. 

When  to  Remove  Sutures. — Lower  two  on  second  day,  the  rest  alter- 
nately, according  to  position,  on  third  and  fourth  day.  Soft  food  till 
union  is  complete.  The  less  conversation  the  better.  The  last  observa- 
tions apply  to  both  hard  and  soft  palate.  Cleft  of  both  hard  and  soft 
palate  may  be  dealt  with  at  one  operation. 

Palate,  Non-Malignant  Tumoes  of,  are  usually  either  (1)  cystomata,  or 
(2)  fibromata,  or  (3)  papiUomata.     Abscess  also  occurs. 

Palate,  Ulcebation  of,  a  frequent  result  of  syphUis,  but  not  always  spe- 
cific.    Treatment. — Mercurial  gargles  and  specific  remedies. 

Palate,  Perforation  of,  the  result  of  disease  (syphilis,  more  rarely 
small-pox  and  measles)  or  injury,*  may  require  an  obturator. 

Paracentesis  Abdominis. — Position  of  Patient. — On  side  near  edge 
of  bed.  An  ink-mark  may  be  made  exactly  in  median  Une,  midway  be- 
tween umbilicus  and  pubes,  as  patient  Hes  on  his  back  before  turning  him 
on  his  side.  Preparation. — Ascertain  by  percussion  presence  of  fluid  in 
spot  to  be  pierced.  Bladder  should  be  empty.  Apply  a  broad  flannel 
belt  round  abdomen  with  its  ends  behind  held  by  an  assistant,  who  keeps 
up  gentle  pressm-e  while  the  fluid  flows,  and  finally  secures  it.  The  tap- 
ping may  be  done  through  a  hole  in  it.  Use  a  cannula  with  an  india-rub- 
ber tube  leading  into  a  bucket.  Have  ready  strapping  and  pad  of  lint  to 
apply  after  operation.  Incise  skin  at  point  where  the  trocar  is  to  be 
thrust  in.  Dangers. — (1)  Hemorrhage,  from  not  keeping  to  the  middle 
line ;  (2)  wound  of  bladder,  from  not  emptying  it ;  (3)  wound  of  bowel, 
from  not  tapping  in  a  thoroughly  dull  spot,  or  from  plunging  trocar  in  too 
deeply ;  (4)  fainting. 

Paracentesis  Pericardii. — An  operation  of  extreme  dehcacy.  Use 
the  aspirator.  Place  of  Puncture. — Fifth  intercostal  space,  two  inches  from 
sternum.  Mark  spot  with  ink.  Use  No.  1  or  2  Dieulafoy's  needle.  As- 
pirator cock  must  be  turned  as  soon  as  needle-point  is  beneath  skin,  so 
that  fluid  may  rush  through  needle  the  moment  pericardium  is  opened. 
Direct  needle  upward  and  inward,  and  hold  it  perfectly  steady. 

Paracentesis  Thoracis. — Formerly  done  with  common  trocar  and 
cannula  ;  now  usually  with  an  aspirator.  Position  of  patient,  sitting  up  in 
bed.  Preparations. — Ascertain  by  percussion,  etc.,  presence  of  fluid.  Place 
taps  of  aspu'ator  in  proper  position.  Place  of  Puncture. — Fifth  intercostal 
space  in  mid-axUlary  line,  or  a  lower  space  more  posteriorly,  e.g.,  seventh, 
near  angle  of  scapula.  Both  may  be  tried  if  fluid  do  not  come  through 
the  first.  Operation. — Punctvire  skin  with  a  lancet.  Insinuate  aspirator 
needle  with  a  twisting  motion  over  lower  rib,  close  to  it  (because  inter- 
costal artery  is  near  upper  rib).  Then  plunge  needle  smartly  through 
pleura  ;  turn  cock  of  aspirator  and  collect  fluid.  Whether  it  is  or  is  not 
such  a  serious  matter  to  admit  au*  into  the  pleural  cavity  has  been  the 


PENIS.  189 

subject  of  many  papers  and  speeches.  For  references,  see  Neale's  "Medical 
Digest,"  p.  240.  Dangers. — Wounding  (1)  intercostal  vessels,  (2)  lung,  (3) 
diaphragm,  (4)  admission  of  air  and  consequent  collapse  of  lung,  empyema, 
etc.  (?),  (5)  ruptiu-e  of  pleura  or  capillaries  by  excessive  suction  with  the 
aspirator,  (6)  sudden  death  {see  Medical  Times,  vol.  ii.,  1875,  p.  382,  etc.). 
If  it  is  desired  to  make  a,  free  incision,  this  is  easily  done  by  cutting  along 
a  grooved  needle  used  as  a  director.  Keep  close  to  rib  below  the  space. 
A  counter-opening  can  be  made  either  in  the  same  way  as  the  first,  or  by 
the  hejp  of  a  long  bent  probe  or  director,  inserted  to  be  cut  down  upon. 
Parotid  Tumors. — Divided,  for  practical  purposes,  into  (1)  innocent, 

(2)  malignant.  Former  commence  near  lobe  of  ear  as  small,  hard  swell- 
ings, perhaps  originally  enlargements  of  a  lymphatic  gland.  They  are 
fibrocartilaginous.  Increasing,  they  tend  to  grow  outward  as  a  square 
mass,  and  inward  so  as  to  displace  part  or  whole  of  the  parotid.  But  can- 
cerous tumors  are  more  diffuse,  more  fixed,  more  painful,  increase  faster, 
and  tend  to  infect  the  lymphatics  of  the  neck.  Treatment. — A  movable 
tumor  corresponding  to  the  first  description  above  given  should  be  ex- 
cised ;  a  malignant  tumor  is  fixed,  and  can  rarely  be  advantageously 
meddled  with.  In  excising  a  parotid  tumor,  cut  as  much  as  possible  in 
the  direction  of  the  fibres  of  the  facial  nerve,  and  keep  the  edge  of  the 
knife  toward  the  tumor.  Simple  tumors  can  sometimes  to  a  great  extent 
be  shelled  out.  Facial  paralysis,  which  sometimes  follows  these  opera- 
tions, is  usually  incurable.  Remember  the  size  of  the  vessels  embedded 
in  the  parotid.  Eemember  also  position  of  Steno's  duct,  a  wound  of  which 
may  cause  saHvary  fistula. 

Pelvis,  Injuries  of,  are  thus  classified  by  Birkett:  1,  Contusions 
involving  the  soft  parts  in  contact  with  the  outside  of  the  pelvis ;  2,  frac- 
tures and  dislocations  of  the  bones  forming  the  pelvis ;  3,  injuries  of 
those  organs  in  relation  with  the  pelvis  which  are  connected  with  the  func- 
tions (A)  of  micturition,  (B)  of  generation,  male  and  female,  (C)  of  defe- 
cation.    See  Bladdeb,  Eectum,  Urethra,  Perinjeum,  Fractures,  etc. 

Penis. — Most  common  affections  are  venereal.  Others  are  congenital 
malformations,  usually  sUght ;  phimosis  and  paraphimosis ;  herpes  pre- 
putii,  warts,  elephantiasis,  cancer,  gangrene,  priapism. 

Penis,  Congenital  Malformations  of. — (1)  Hypospadias  ;  (2)  epispadias  ; 

(3)  deficiency  of  corpus  spongiosum  ;  (4)  the  penis  may  be  bound  down  to 
the  perinseiun,  between  the  testes,  so  as  to  arch  forward  during  erection 
(I  have  seen  one  such  case,  and  I  think  Mr.  Erichsen's  case  of  "Adhesion  of 
Penis  to  Scrotum "  was  probably  exactly  similar)  ;  (5)  adhesion  between 
glans  and  prepuce. 

Hypospadias. — Urethra  stops  short  on  lower  surface  of  penis.  Slight 
degrees  common,  and  of  no  consequence.  If  it  extend  far  backward,  e.g., 
so  that  the  urethra  opens  near  the  root  of  the  penis,  both  urine  and  semen 
are  emitted  at  right  angles  to  the  penis.     But  even  in  such  cases  paternity 


190  PENIS. 

is  not  absolutely  impossible.  Plastic  surgery  is  sometimes  successful  in 
such  cases  {vide  Wood,  Medical  Times,  vol.  i.,  1875  ;  Jordan,  Lancet,  vol. 
i.,  1876). 

Epispadias. — Urine  flows  from  a  groove  on  upper  surface  of  base  of 
penis.  .  Always  combined  with  extroversion  of  bladder,  q.  v. 

In  such  a  case  as  4  (above)  divide  the  adhesion.  Congenital  adhesion 
between  prepuce  and  glans  may  be  torn  asunder  with  any  small  blunt  in- 
strument. With  malformations,  the  following  condition  may  be  classed 
when  congenital. 

Phimosis. — Prepuce  cannot  be  drawn  back.  Either  congenital,  or  the 
result  of  sweUing,  usually  inflammatory  and  specific,  of  the  prepuce  {ac- 
quired). Consequences  of  Congenital  P/imosis.— Local  irritation,  balanitis, 
calculous  concretions  between  prepuce  and  glans.  Urinary  obstruction 
and  vesical  irritation.  Masturbation.  Reflex  convulsions,  paralyses,  and 
contractions  (SajTe).  Even  hip-joint  disease  (BarweU).  Treatment  of 
Congenital  Phimosis. — Circumcise.  If  circumcision  be  objected  to,  success 
will  generally  attend  steady  efforts,  repeated  day  by  day,  to  draw  back  the 
prepuce.  Acquired  Phimosis  must  be  treated  according  to  the  indications 
of  each  case.  Generally  rest  in  bed,  cleanliness  and  patience  suffice  in  an 
acute  case  ;  but  occasionally  it  is  absolutely  necessary  to  either  circumcise, 
slit  up,  or  forcibly  dilate  the  prepuce.  If  the  prepuce  be  itself  inflamed, 
it  is  best  to  merely  slit  it  up  in  the  dorsal  middle  line. 

Paraphimosis. — The  j)repuce  behind  the  glans  strangles  it,  and  cannot 
be  pulled  forward  by  the  patient.  Treatment. — Invariable  success,  except 
in  old  cases,  may  be  expected  from  IVIr.  Furneaux  Jordan's  plan  of  com- 
pressing the  penis  gently  and  patiently  in  the  cavity  formed  by  hollowing 
slightly  the  palms  of  the  two  hands  and  then  opposing  them.  Soon  the 
oedema  yields,  and  then  the  paraphimosis  is  reduced  by  the  fingers  and 
thumbs.  The  preliminary  compression,  if  gently  and  patiently  done, 
makes  bearable  an  otherwise  intolerably  painful  procedure.  2.  In  case  of 
need,  the  following  operation  may  be  done  :  draw  the  glans  forward,  "  then, 
passing  the  point  of  a  narrow-bladed  scalpel  into  the  sulcus  on  the  dorsum 
of  the  penis,  make  a  perpendicular  incision  about  one-third  of  an  inch  in 
length  through  the  integuments  at  the  bottom  of  the  groove  directly  across 
it"  (Erichsen).     Thus  the  constricting  band  is  divided. 

Herpes  Peeputh  may  be  mistaken  for  chancre.  Distinguishable  by  its 
extremely  superficial  character,  by  the  number  of  vesicles  at  first,  and 
af  tei'ward  by  there  being  nothing  to  see  except  excoriation  and  pus.  Lasts 
a  few  days.  Readily  cured  by  washing  once  a  day  with  hot  water  and 
dressing  with  zinc  ointment.  Patients  subject  to  it  should  never  use  soap 
to  the  part,  but  wash  daily  with  water  only  and  dry  thoroughly. 

Penis,  Warts  on. — For  pathology,  etc.,  vide  Condylomata  and  Syphilis. 
Treatment. — Snip  off  with  scissors.  Dress  with  cupri  sulph.  pulv.  and 
zinci  oxid.     Or  keep  constantly  applied  lint  soaked  in  acid,  nitric,  dil., 


PERINiEUM.  191 

3  ij. ;  aquae,  Oj.  In  obstinately  recurrent  cases  the  prepuce  should  be  worn 
back  and  the  glans  kept  exposed. 

Penis,  Cancer  or.  Epithelioma. — (Scirrhus  is  extremely  rare.)  Usually 
commences  after  middle  life,  on  the  glans,  as  a  firm  warty  growth,  with  a 
broad  base.  Its  progress  resembles  that  of  cancer  elsewhere,  but  it  is 
usually  slow,  and  it  seldom  infects  other  organs.  Treatment. — Thorough 
excision.  Amputation  not  necessary  where  a  clean  sweep  can  be  effected 
without  so  radical  a  measure.  When  there  is  sufficient  doubt  about  the 
diagnosis,  give  a  fair  trial  to  antisyphilitic  remedies. 

Penis,  Gangrene  of. — Besides  the  ordinary  simple  and  specific  inflam- 
mations to  which  the  organ  is  liable,  Humphiy  instances  the  following  as 
recorded  causes  of  gangrene  :  typhus  and  paraplegia.  Spontaneous  gan- 
grene has  been  observed  (Partridge). 

Priapism  is  rather  a  symptom  than  a  disease,  and  points  to  one  of  two 
classes  of  causes:  (1)  reflex  irritation,  e.g.,  from  gonorrhoea,  prostatic  dis- 
ease, and  injuries  to  penis ;  (2)  paralyses,  e.g.,  from  injuries  to  spinal  cord. 

The  penis  is  liable  to  many  other  affections  common  to  the  ordinary 
tissues,  and  these  are  frequently  mistaken  for  specific  affections ;  e.g.,  I 
have  known  one  of  the  most  able  speciaHsts  in  London  to  diagnose  an  in- 
flamed lymphatic  as  a  hard  chancre.  Phlebitis  occurs  occasionally,  pro- 
ducing the  ordinary  symptoms. 

Penis,  Injuries  of. — Chief  points  in  connection  with  these  are  that  (1) 
extensive  contusion  produces  priapism,  lasting  for  days ;  (2)  wounds 
should  be  carefully  adjusted,  and  united  by  sutures  ;  (3)  bleeding  is  easily 
arrested  by  cold  and  pressure  ;  (4)  swelling  of  the  penis  in  children  should 
suggest  the  possibihty  of  a  string  tied  round  the  organ  having  been  hidden 
by  the  swelling. 

Perinaeum. — Chief  affections  are  abscess  and  fistula.  Hernia  and  a 
misplaced  testicle  in  the  perinaeum  occur  very  rarely. 

Perineum,  Abscess  in  the. — Commonly  caused  by  a  slight  urinary  extrav- 
asation behind  a  stricture.  Symptoms. — At  first  attention  is  attracted  by 
fever,  perhaps  rigors,  and  pain  in  the  region  of  the  bulb.  A  hard  lump  is 
felt ;  this  increases  and  softens.  Treatment. — Open  early ;  incise  in  the  mid- 
dle line.  If  a  stricture  coexist,  it  is  good  practice  to  divide  it  at  the  same 
time  (external  urethrotomy).  At  all  events  the  stricture,  being  the  cause 
of  the  abscess,  must  be  treated. 

Perineal  Fistula. — A  result  of  perineal  abscess.  Generally  closes  when 
the  original  stricture  of  tbe  urethra  is  cured.  Perineal  fistulas  occasionally 
have  theh'  origin  in  comparatively  remote  affections,  e.g.,  cancer  within  the 
pelvis.  In  order  to  cure  a  perineal  fistula  it  may  be  necessaiy  to  (1)  teach 
the  patient  to  catheterize  himself  four  times  a  day,  or  (2)  to  incise  the  fis- 
tula freely,  or  (3)  to  cauterize  it ;  (4)  it  is  to  be  remembered  that  the  pres- 
ence of  a  small  calculus  may  prevent  healing  (Thompson). 

Perineum,  Injuries  to. — Causes. — Blows  received  in  climbing  over  rail- 


192  PHARYNX. 

ings,  etc.,  or  by  being  thrown  on  the  pommel  of  the  saddle.  Pressure  of 
child's  head  in  parturition.  The  injuries  vary  in  seriousness  from  slight 
bruises  to  injuries  involving  such  important  structvires  as  the  urethra,  rec- 
tum, and  bladder.     Parturition  may  result  in — 

Ruptured  Ferinceum. — Varies  much  in  extent.  The  more  extensive 
ruptures  often  allow  the  walls  of  the  vagina,  rectum,  or  bladder,  as  weU  as 
the  uterus,  to  prolapse.  The  utmost  annoyance  may  be  caused  by  inabil- 
ity to  hold  the  faeces.  Treatment. — Sutures  should  be  put  in  at  the  time 
when  the  injury  occurs.  Otherwise  it  is,  except  in  trifling  cases,  advisable 
to  postpone  the  operation  until  the  child  can  be  weaned  and  the  mother  re- 
stored to  the  best  attainable  health.  Operation. — Scalpels  with  short  and 
with  long  handles,  forceps  long  and  short,  strongly  curved  needles  with 
handles  {e.g.,  Baker  Browne's  needle),  sutvires  of  silk,  whip-cord,  and  silver 
or  catgut.  Ligature,  artery  forceps,  etc.  Handled  sponges.  Duck-bill 
speculum ;  retractors.  Lithotomy  position.  Assistant  holds  duck-bill 
speculum  against  anterior  wall  of  vagina.  Perinseum,  etc.,  is  shaved. 
Square  flaps  of  skin  and  mucous  membrane  are  marked  out  on  either 
side  of  rupture,  involving  part  of  the  vaginal  surface  of  the  recto-vaginal 
septum,  and  widening  somewhat  toward  the  surface  of  the  perinseum. 
The  flaps  to  be  reflected  thoroughly,  not  the  slightest  bit  of  mucous  mem- 
brane to  be  left.  But  the  flaps  need  not  be  removed  altogether :  should 
rather  be  left  and  sewn  together  over  the  vaginal  edge  of  the  wound.  Pass 
posterior  sutures  first.  It  should  go  through  recto-vaginal  septum,  i.e., 
should  never  appear  in  the  rupture  at  all.  Suture  to  enter  and  leave  skin 
at  one  inch  from  edge  of  wound.  Fasten  on  two  pieces  of  elastic  catheter, 
or  else  use  button  suture.  When  deep  sutures  are  tightened,  wound  gapes 
superficially.  To  remedy  this  add  a  few  small  silver  sutures.  Before  su- 
tures are  tightened,  stop  all  hemorrhage.  Iced  water  usually  recom- 
mended for  this.  I  think  hot  water  will  be  found  to  answer  better  (120° 
to  130°  Fahr.).  The  hemorrhage  will  be  less  if  the  mucous  membrane 
only,  without  any  of  the  subjacent  erectile  tissue,  be  shaved  off  (T.  Smith). 
To  lessen  tension,  the  superficial  fibres  of  the  sphincter  ani  may  be  divided 
laterally  ;  or  lateral  incisions  may  be  made  a  short  distance  outside  the  ex- 
ternal ends  of  the  sutures.  Bowels  should  have  been  well  opened  before, 
and  should,  after  the  operation,  be  kept  closed  by  liq.  opii,  TTl  x.,  bis  die,  for 
a  fortnight.  For  ten  days  draw  off  urine  thrice  a  day  with  a  catheter ; 
and  for  a  week  or  two  afterward  patient  should  urinate  on  her  hands  and 
knees.  Pay  attention  to  the  diet.  Keep  the  wound  and  vagina  clean. 
After  washing  with  any  antiseptic  lotion,  dry  carefully  and  gently. 

Periostitis. —  Vide  Bone. 

Phagedaena. —  Vide  Ulceks  and  Syphiijs. 

Pharynx. — Its  chief  affections  are  inflammation,  abscess,  tumors, 
epithelioma,  syphilitic  disease,  ulceration,  wounds,  and  presence  of  foreign 
bodies. 


PROSTATE.  193 

Congenital  Discontinuity  of  Phakynx  and  (Esophagus. —  A  complete 
monograph  on  this,  by  Ilott  of  Bromley,  is  in  "  Pathological  Transactions 
for  1876." 

Acute  Diffuse  Pharyngitis. — Highly  dangerous.  Usually  spreads  from 
fauces.  Dyspnoea,  dysphagia.  Great  swelling,  internal  (and  often  also 
external).  Progress  rapid.  Termination. — Usually  death,  in  a  few  days, 
either  suddenly  or  with  signs  of  sinking.  Pathology. — Inflammation  of 
cellular  tissue  of  pharynx  and  of  oesophagus  ;  great  oedema  ;  often  suppura- 
tion. Treatment. — Supporting,  stimulating.  Enemata.  Quinine.  Lai-yn- 
gotomy  to  avert  danger  of  suffocation. 

Post-Pharyngeal  Abscess. — Cause. — Often  caries  of  cervical  vertebrae. 
Most  dangerous  in  children  :  because  then  may  not  be  diagnosed  till  it  has 
produced  suffocation.  May  open  externally  in  neck.  Treatment. — Puncture 
with  an  abscess  knife  having  its  blade,  except  near  the  point,  protected  by 
lint.    Finger  may  be  used  as  a  director. 

Ulcers  of  Pharynx,  usually  syphilitic  in  adults  and  sometimes  strumous 
in  children.     Treatment. — See  Treatment  of  SYPmus  and  Scrofula. 

Dilatations  and  Pouches  of  Pharynx  occvu'.  Food  is  apt  to  lodge  in 
them.  Diagnose  by  the  history  given  by  the  patient.  Regurgitation  some- 
times occurs,  or  patient  may  be  able  to  empty  the  pouch  by  external  pres- 
sure.    Secondary  laryngitis  may  occur. 

Pharynx,  Foreign  Bodies  m. —  Vide  (Esophagus. 

Phimosis. —  Vide  Penis. 

Prostate. — Chief  Affections. — Inflammation,  acute  and  chronic  ;  ab- 
scess, periprostatic  abscess  ;  hypertrophy  ;  simple  tumors  ;  atroj)hy ;  tu- 
bercle ;  cysts  ;  malignant  disease. 

Prostate,  Acute  Inflammation  of. — Causes. — Gonorrhoea,  cystitis,  strong 
injections,  cauterization,  mechanical  injuries,  e.g.,  from  sounds.  Catching 
cold,  alcoholic  excesses,  and  sexual  excitement  will  determine  an  attack  if 
some  other  influence  pre-exist,  such  as  gonorrhoea,  gout,  or  rheumatism. 
Symptoms. — Local  pain  extending  into  loins  and  back,  weight,  and  fulness. 
Frequent  and  painful  micturition,  especially  painful  at  the  close  of  the  act. 
Pain  becomes  shooting  and  throbbing.  Anal  and  perineal  tenderness  and 
fulness.  Defecation  painful.  Micturition  often  difficult  or  impossible. 
Fever.  Pus  in  urine  when  abscess  bursts.  Per  anum  the  prostate  can  be 
felt  enlarged.  Piles  may  be  induced.  Treatment. — Rest  in  bed.  An  aperi- 
ent to  commence  with.  Antimony.  Acetate  of  potash  in  fuU  doses.  Ten 
to  twenty  leeches  to  perinseum  and  round  anus.  Hot  hip-bath.  Poultices 
to  perinseum.  Retention  usually  reheved  by  hot  baths  and  liq.  opii.  Or 
a  soft  catheter  may  be  passed.  Prostate  remains  for  a  long  time  aftexwai-d 
enlarged  and  hard,  obstructing  flow  of  urine. 

Prostate,  Chronic  Infl.\mmation  of. — Usu9,lly  a  sequel  of  acute.  Gener- 
ally, but  not  always,  enlargement  of  the  gland.  Obstruction  to  passage  of 
urine.     Anal  and  perineal  pain.     Gleety  discharge.     Sometimes  nocturnal 


194  PROSTATE. 

emissions.  Pain  in  sexual  intercourse.  Irritable  bladder.  Treatment. — 
Rest.  Regular  and  unstimulating  diet.  Tonics  and  stomacliics.  Iron, 
with  a  mild  aperient.  Counter-irritation  to  perineeum.  For  the  noctur- 
nal emissions,  make  tlu*ee  or  four  applications  of  a  solution  of  nitrate  of 
silver  (gr.  x.-xxx.  to  3  j.)  to  the  prostatic  part  of  the  urethra.  As  Sir  H. 
Thompson  says,  "  To  be  successful  an  efficient  instrument  is  absolutely- 
necessary,  as  well  as  care  in  injecting  the  fluid  at  the  right  spot."  For  en- 
largement of  prostate  left  by  acute  inflammation  give  a  prolonged  course 
of  pot.  iod.  and  pot.  bromid.  ;  sea-bathing  and  tonics. 

Prostatic  Abscess. — 1.  Acute. — When  prostatitis  leads  to  abscess  the 
acute  sjonptoms  persist  for  more  than  a  week  or  two,  pain  and  tenderness 
increase,  rigors  probably  occur,  and  the  prostatic  swelling  may  throb. 
Fluctuation  may  be  felt  sooner  or  later,  perhaps  per  rectum.  Abscess  tends 
to  open  into  urethra,  more  rarely  into  rectum.  Either  termination  is  of 
good  prognosis.  In  exceptional  cases,  abscesses  recur  again  and  again. 
Treatment. — Incise  early  in  the  median  line  of  the  perinseum.  Foment  and 
poultice.  "  When  the  suppuration  is  due  to  stricture,  and  probably  ex- 
travasation, the  propriety  of  dividing  the  sti'icture  and  laj'ing  open  the 
perinseum  down  to  the  prostate  cannot  be  questioned"  (Bryant).  2. 
Chronic  Prostatic  Abscess. — Either  a  sequel  of  acute  abscess  or  the  dii'ect 
result  of  old  stricture  of  urethra.  Whole  prostate  may  be  destroyed.  Con- 
dition always  serious.  Chronic  cystitis,  progressive  emaciation.  Treat- 
vient. — Rest,  highly  tonic  and  soothing  regimen,  fresh  air.  Sometimes 
perineal  incision  is  indicated. 

Prostate,  Hypertrophy  or. — A  senile  affection.  Never  occurs  before 
fifty,  usually  over  sixty.  But,  of  old  men,  it  attacks  no  greater  proportion 
than  one-half.  Affects  every  constituent  of  the  prostate,  but  chiefly  the 
muscular  and  fibrous  elements.  Enlargement  may  be  general  or  limited. 
In  the  latter  case,  an  outgrowth  sometimes  occurs  from  the  centre  of  the 
gland  backward  toward  the  bladder,  improperly  called  the  "  enlarged  third 
lobe."  Either  lateral  lobe  may  be  disproportionately  hypertrophied.  Iso- 
lated, almost  independent,  tumors  (myomata)  are  very  common  in  the  sub- 
stance of  hypertrophied  prostates.  They  contain  very  little  glandtdar  sub- 
stance, and  that  ill- developed.  Effect  on  the  Urethra. — Prostatic  part  of 
tn-ethra  is  lengthened,  and  its  antero-posterior  diameter  increased,  while  its 
transverse  diameter  is  lessened.  Its  direction  is  altered  in  a  manner  which 
varies  according  to  the  part  of  the  gland  which  is  enlarged.  The  urethra 
takes  an  abnormal  curve  whose  conca^dty  corresponds  to  the  lateral  lobe 
most  enlarged.  So  also  the  vesico-urethral  orifice  takes  a  crescentic  form 
with  the  concavity  toward  the  enlarged  lobe.  When  the  "  third  lobe  "  is 
enlarged,  the  urethra  is  bent  suddenly  upward  in  front  of  it.  Occasional 
outgrowth  of  median  portiotn  of  prostate,  overlapping  vesico-urethral  ori- 
fice as  a  valve,  which  obstructs  the  flow  of  urine.  Size  of  enlarged  prostate 
often  very  considerably  increased.     Diameter  of  over  four  inches  and 


PKOSTATE.  195 

weight  twelve  ounces  known.  A  weight  of  even  one  ounce  signifies  hyper- 
trophy. Consistence  varies.  Symptoms. — (In  earliest  stage  nil.)  Diminu- 
tion of  force  with  which  urine  is  ejected.  Frequent  desire  to  micturate  ; 
micturition  is,  as  it  were,  incomplete.  Uneasiness  and  weight  about  peri- 
naeum  and  neck  of  bladder.  Tenesmus.  Hemorrhoids  tend  to  develop. 
Sometimes  flattened  stools.  After  a  time,  chronic  cystitis.  Sometimes 
urethral  discharge,  or  frequent  erections  of  penis.  Urinary  obstruction 
increases ;  bladder  overflows  at  night.  Bladder-dulness  tends  to  ascend 
higher  and  higher  in  abdomen.  General  health  gets  worse.  Accidental 
circumstances,  e.g.,  slight  excesses,  bring  on  attacks  of  retention.  Small 
hemorrhages.  Urinary  changes  similar  to  those  of  chronic  cystitis.  Neu- 
tral or  alkaline  reaction.  Mucus.  Phosphatic  masses,  soft  and  white. 
Muco-pus.  Diagnosis  is  usually  determined  by  examination  with  the  left 
forefinger  in  the  rectum.  Information  may  be  thus  acquired  concerning 
the  size,  shape,  and  consistence  of  the  prostate,  and  concerning  the  pres- 
ence, absence,  or  position  of  fluctuation.  Such  examination  is  assisted  by 
simultaneously  manipulating  a  catheter  in  the  urethra.  "  If  the  catheter 
has  passed  easUy,  say  for  nine  or  ten  inches,  and  still  no  urine  flows ;  and 
if,  in  addition,  while  follomng  its  course,  the  handle  has  become  more  than 
usually  depressed,  there  Avill  be  little  doubt  in  respect  of  the  existence  of 
prostatic  enlargement"  (Thompson).  Of  course,  with  a  healthy  urethra, 
urine  should  flow  through  a  catheter  entered  six  and  a  liaK  to  eight  inchea 
When  the  catheter  is  deflected  laterally  in  passing,  the  side  toward  which 
the  handle  turns  is  probably  the  more  enlarged.  An  examination  should 
be  made  with  a  short-beaked  sound,  such  as  that  pictured  in  Holmes's 
"System,"  vol.  iv.,  p.  926  ;  or  one  of  those  described  and  illustrated  by 
Teevan  in  Lancet,  vol.,  i.  1880.  With  this  a  possible  calculus  should  be 
searched  for.  Stricture  of  urethra  contrasts  with  prostatic  obstruction  in 
that  (1)  it  occurs  anteriorly  to  prostatic  urethra,  (2)  it  appears  before 
middle  hfe,  (3)  the  stream  of  urine  is  more  diminished  in  volume  (in  pros- 
tatic obstruction  it  is  rather  force  than  volume  which  is  lessened).  Other 
conditions  from  which  prostatic  enlargement  has  to  be  distinguished 
(though  it  may  coexist  with  them)  are  vesical  calculus,  tumor  of  the  bladder, 
atony  of  the  bladder,  paralysis  of  the  bladder.  Compare  with  the  symptoms 
of  these  given  under  Diseases  of  the  Bladder.  Treatment. — A  catheter 
should  be  passed  twice  a  day,  oftener  where  urination  is  extremely  feeble. 
Patient  should  learn  to  catheterize  himself.  Elastic  instruments  preferable. 
Silver  prostatic  catheters  are  either  made  with  a  large  curve  or  else  with  a 
short  beak.  Great  in-itability  of  the  bladder,  disturbing  sleep,  may  re- 
quire a  vulcanized  india-rubber  .catheter  to  be  tied  in  all  night.  Treat  co- 
incidently  such  comj)Hcations  as  catarrh  of  the  bladder  {quod  vide).  At- 
tend to  the  general  health  and  regulate  the  habits.  Clothe  lower  limbs 
warmly.  Operations  on  diseased  prostate  are  by  most  stu-geons  avoided. 
Prostate,  Atrophy  of. — Unusual  and  unimportant. 


196  PSOEIASIS. 

Peostate,  ]VL\ligna3?t  Disease  of. — Encephaloid  is  the  form  which  affects 
this  gland.  Occvirs  only  in  childhood  and  at  advancing  age.  Progress 
very  rapid  in  children.  The  symptoms  are  the  usual  ones  of  cancer, 
added  to  those  of  prostatic  obstruction,  including,  especially,  severe  pain, 
occasional  hemorrhages,  and  cachexia.  Lymphatic  glands  of  lumbar,  and 
sometimes  of  ihac  region,  enlarge.  Urinary  deposit  may  exhibit  cancer 
cells  when  examined.  Treatment. — If  catheterism  cannot  be  avoided,  be 
as  gentle  as  possible.  ReHeve  pain  by  anodynes,  etc.  Treat  hemon-hage 
on  general  principles.  Support  the  general  strength.  Perhaps  Chian  tur- 
pentine, which  Clay  appears  to  have  found  useful  in  carcinoma  uteri,  might 
be  fairly  tried  here. 

Prostate,  Tubercle  of. — Very  rare.  Always  secondary.  Symptoms 
probably  raise  a  suspicion  of  calculus  ;  but  no  stone  being  found,  and 
coincidence  of  symptoms  of  tubercle  elsewhere,  correct  the  diagnosis. 
Avoid  instrumental  interference  ;  protect  from  other  sources  of  irritation  ; 
and  treat  the  tubercle  and  its  results,  e.g.,  abscess,  on  general  principles. 

Prostate,  Cysts  of. — Small  cysts  sometimes  occur.  Often  numerous  ; 
often  contain  small  concretions.  Probably,  dilatations  of  gland-tubules. 
No  known  symptoms  of  consequence ;  therefore  no  treatment.^ 

Psoas  Abscess. — See  Spdje,  Cartes  of  ;  also  Abscess,  Chronic. 

Psoriasis. — A  "  squamous  "  disease  of  the  skin,  always  chronic,  often 
recurrent — especially  in  spring  and  autumn — often  syphilitic,  sometimes 
hereditary.  The  sufferers  ai-e,  for  the  most  part,  in  perfect  health,  ex- 
cept when  syphilitic.  Infants  and  very  old  people  are  almost  exempt. 
Psoriasis  is  a  superficial  dermatitis,  without  subepidermic  effusion,  i.e., 
without  causing  vesicles.  It  forms  red  spots  or  patches,  covered  with 
whit«,  shining  (epidermal)  scales.  The  classification  of  psoriasis  into 
many  varieties  is  of  little  more  than  nominal  importance,  e.g.,  psoriasis 
guttata,  psoriasis  diffusa,  psoriasis  circinnata  (formerly  "  lepra  vulgaris  "), 
psoriasis  nummularis,  etc.,  psoriasis  palpebrarum,  psoriasis  scrotalis, 
psoriasis  palmaris,  psoriasis  plantaris,  etc.  Diagnosis  of  Syphilitic  from 
Common  Psoriasis.— Syphilitic  is  (1)  generally  darker  in  color  ;  (2)  rarely 
affects  knees  and  elbows  ;  (3)  is  frequently  palmar  and  plantar— the  latter 
is  always  syphilitic  ;  (4)  may  lead  to  painful  fissures,  and  even  ulcers.  Non- 
specific psoriasis  has  for  its  favorite  seats  the  extensor  sides  of  the  knee 
and  elbow,  because  there  the  skin  is  coarse  and  drj'.  Of  course,  the  his- 
tory may  be  inquired  into.  Treatment.— Yigorons  external  treatment,  and 
arsenic  internally.  Begin  with  two  Turkish  baths  or  several  warm 
baths,  using  plenty  of  soap.  Locally,  prefer  ung.  picis.  Olive  oil,  in  con- 
junction with  repeated  baths,  may  suffice*  Crocker  recommends  thymol 
ointment  (gr.  x.-xxx.  to  3].).     Ung.   acidi  chrysophanici  (gr.  xx.  to   §].) 


1  The  above  account  of  diseases  of  the  prostate  is  chiefly  condensed  from  the 
writings  of  Sir  Henry  Thompson. 


PYEMIA.  197 

(liable  to  stain  linen).  Begin  with  three  minims  of  liq.  arsenicahs  three 
times  a  day,  and  gradually  increase  to  six  minims.  Note. — Arsenic  at  first 
appears  to  aggravate  the  disease.  Give  it  after  meals.  Other  internal 
remedies  are  tinct.  cantharidis  and  iodide  of  potassium  (gr.  x.  doses). 

For  syphilitic  psoriasis,  rely  mainly  on  ordinaiy  antisyphilitics. 

Pyaemia. — A  disease  characterized  by  remittent  fever  and  the  foi-ma- 
tion  of  multiple  collections  of  pus  in  various  parts  of  the  body.  It  is  a 
near  ally  of  septicaemia  and  of  ordinary  surgical  fever  ;  but  the  scattered 
abscesses  are  characteristic.  Causes. — The  immediate  cause  is  granted  to 
be  the  absorption  of  pus  or  of  septic  material  into  the  blood.  It  is  stUl 
disputed  whether  pus,  in  order  to  produce  pysemia,  must  be  putrefying ; 
and  it  is  stUl  uncertain  whether  the  immediate  cause  of  pyaemia  can  be  ab- 
sorbed through  the  mucous  membranes,  or  whether  it  can  enter  only 
through  an  open  wound.  Advocates  of  the  germ  theory  suppose  that  al- 
most every  case  of  pysemia  is  due  to  the  entrance  of  microscopic  germs 
into  open  wounds,  and  pi'oduce  strong  experimental  proof  of  that  belief ; 
but  how  those  germs  cause  the  multiple  abscesses  is  not  so  clear.  The 
immediate  cause  of  each  scattered  abscess  ("metastatic"  abscesses,  they 
are  often  called)  is  venous  thrombosis  and  embolism  ;  but  what  is  the 
exact  way  in  which  the  thrombosis  is  brought  about  ? '  Some  of  the  ab- 
scesses near  the  original  wound  are  merely  terminations  of  lymphatic 
inflammations,  a  track  of  inflamed  lymphatics  being  sometimes  traceable 
to  them  from  the  wound.  Cases  of  pytemia  sometimes  occur,  apparently 
spontaneous  in  origin,  and  are  called  "idiopathic  pyaemia."  It  must  be 
remembered  that  their  idiojjathic  nature  rests  on  negative  evidence  only. 

Conditions  predisposing  to  pycemia  are  (1)  bad  ventilation  and  foul  air; 
(2)  accumulation  of  many  wounds  in  one  ward  ;  (3)  neglect  of  having  sick- 
rooms thoroughly  and  periodically  cleansed  ;  (4)  dirty,  and  careless  dress- 
ing and  nursing  ;  (5)  unnecessarily  meddling  with  and  disturbing  injuries  ; 
(6)  bad  drainage  ;  (7)  other  analogous  conditions.  A  second  set  of  causes 
belong  more  personally  to  the  patient.  They  include  (1)  drunken  habits, 
(2)  old  age,  (3)  weak  constitution,  (4)  unmanageableness  and  restlessness. 
Many  sHght  cases  of  feverishness  have  been  converted  into  acute  blood- 
poisoning  by  severe  exercise,  e.g.,  ascending  a  mountain.  "You  will  find 
in  every  day's  practice  that  fatigue  has  a  larger  share  in  the  promotion  or 
permission  of  disease  than  any  other  single  causal  condition  you  can 
name  "  (Paget).  "  After  wounds,  children  are  singularly  free  from  pj'semia  " 
(Paget).  Pathology. — The  nature  of  the  changes  in  the  blood  is  unknown. 
Localities  attacked  are  (1)  joints,  (2)  viscera,  (3)  serous  membranes,  (4) 
mucous  membranes,  (5)  skin  ;  and  to  these  may  be  added  the  veins,  lym- 
phatics, and  cellular  tissue  throughout  the  rest  of  the  body.  In  the  viscera 
are  found  low  inflammations  and  metastatic  abscesses.     The  affected  joints 

'  See  note  on  Microscopic  Organizations  in  Appendix. 


198  EANULA. 

and  serous  cavities  are  inflamed  and  filled  with  pus.  External  to  the  joints 
are  oedema  and  flushes  of  redness.  The  affected  mucous  membranes  are 
inflamed,  and  may  give  vent  to  great  discharge.  This,  in  the  case  of  the 
gastro-intestinal  canal,  causes  diarrhoea  and  even  vomiting.  When  the 
skin  is  affected,  blood-poisoning  usually  shows  itself  as  erysipelas  {quod 
vide),  or  as  pustular  inflammation.  Veins  become  the  seat  of  thrombosis, 
with  or  without  precedent  inflammation.  Jaundice  and  suppression  of 
Tirine  sometimes  occur  in  the  course  of  pyaemia.  Symptoms  and  Course. — 
1.  Of  acute  pyaemia.  Kigors  and  feehng  of  illness.  Perhaps  purging  and 
vomiting,  with  or  without  jaundiced  hue  of  skin.  High  temperatm-e. 
Eapid  and  frequent  pulse.  Erysipelatous  inflammation  of  neighborhood 
of  wound.  Tender  and  inflamed  glands.  Acute  pneumonia  or  pleurisy. 
Finally,  "  the  patient — flushed,  anxious,  restless,  even  delii-ious — is  in  a 
hopeless  condition,  with  prostration  and  rapid  sinking.'"  Duration: 
about  five  or  six  days.  2.  Subacute  or  chronic  pyaemia.  A  typical  case 
presents,  successively,  the  following  symptoms :  Wound  dry  and  inflamed, 
its  edges  swollen.  This  local  inflammation  spreads.  Pain  and  tenderness  ; 
burrowing  of  pus ;  fever  ;  rigors  ;  abscess  forms  near  the  wound  ;  neigh- 
boring joint  swells ;  other  abscesses  form.  Large  lymphatics  and  glands 
may  inflame  and  suppurate.  Fever  continues ;  temperature  rises  and  faUs 
irregularly,  high  rises  usually  coincident  with  rigors.  Distant  joints  swell. 
Progi'essive  emaciation  ;  yellow  skin  ;  no  sleep  ;  no  appetite  ;  despondency. 
Cough  ;  pain  in  chest  (indicating  pleurisy  or  metastatic  pneumonia).  Tongue 
furred  and  dry.  Bed-sores.  Occasional  delirium.  Eyes  duU.  Finally,  utter 
prostration  and  death.  Duration  of  subacute  pya?mia,  two  to  four  weeks ; 
of  chronic,  one  to  five  months.  Prognosis. — Of  acute  cases,  practically 
hopeless.  Chronic  and  mild  cases  may  recover,  especially  if  prime  cause 
can  be  removed.  5aget  relates  a  case  which  lasted  three  years  and  finally 
recovered.  Treatment. — Chiefly  prophylactic.  It  includes  the  whole  art  of 
treating  wounds  properly  {quod  vide).  CleanHness,  quietness,  etc.  Anti- 
septic treatment.  Hospitals  properly  situated,  arranged,  and  ventilated  ; 
wards  periodically  cleansed  and  disinfected ;  clean  bedding  ;  obedient  and 
sensible  nurses.  When  pyaemia  is  actually  developed,  plenty  of  fresh  air, 
diligent  nursing,  feeding  with  milk,  eggs,  etc. ;  cooling  drinks  ;  quinine  (5- 
15  grains  for  a  dose)  ;  morphia  at  night ;  hyposulphite  of  soda  (gr.  xx. 
every  two  hours)  ;  warm  baths  and  wrapping  in  blankets  to  produce  copious 
diaphoresis.  In  chronic  pysemia  amputation  may  be  indicated.  Liq. 
potassae  (  3  j.  ter  die)  to  remove  pysemic  deposits  (Paget).  The  commonest 
surgical  causes  of  pysemia  are  compound  fractures. 

Ranula. — A  cystic  tumor  occurring  in  two  situations,  (1)  close  by 
fr^nxun  linguae,  (2)  between  mylohyoid  muscle  and  mucous  membrane. 
The  latter  form  of  ranula  bulges  externally  between  chin  and  hyoid  bone. 

'  Callender  in  Holmes's  System. 


EECTUM,    DISEASES    OF.  199 

Contents  :  glairy,  mucous  fluid.  But  the  second  form  may  contain  matter 
of  a  cheesy  consistency.  Causes. — Eanulas  are  probably  "retention  cysts," 
but  not  caused  by  obstruction  of  Warton's  duct  (Morrant  Baker).  IVeaf- 
ment. — Open  in  the  mouth,  and  cut  away  a  part  of  the  cyst-wall.  Empty, 
and  if  the  fluid  re-collects,  repeat  the  operation,  in  addition  cauterizing  the 
interior  of  the  cyst. 

Rectum,  Diseases  of  (for  those  of  Anus,  vide  Anus). — Stricture,  can- 
cer, polypus,  malformation,  hemorrhoids  (vide  Hemorrhoids). 

Rectum,  Stricture  of. — Two  kinds,  viz.,  Simple  and  Cancerous.  For 
latter,  vide  Cancer  of  Rectum.  Simple  Stricture. — Causes. — (1)  Contrac- 
tion of  simple  inflammatory  deposit  in  the  walls  of  the  rectum  ;  (2)  syphilis  ; 
(3)  cicati-icial  contraction  after  operative  procedures  ;  (4)  or  after  slough- 
ing caused  by  pressure  during  parturition  ;  (5)  or  after  stnimous,  dysen- 
teric, or  other  ulceration.  The  chronic  inflammation  which  leads  to  stric- 
ture may  be  caused  by  the  impaction  of  foreign  bodies  or  by  the  constant 
irritation  of  hard  fieces.  Pathology. — The  seat  of  a  simple  stricture  is 
marked  by  a  fibrous  deposit,  which  may  extend  wholly  or  partially  around 
the  bowel.  When  slight,  it  lies  usually  in  the  submucous  tissue  ;  but  often 
the  whole  thickness  of  the  rectum  is  afifected.  The  usual  seat  is  from  one 
inch  to  one  inch  and  a  half  above  the  anus.  Bowel  above  stricture  dilated 
and  hj^ertrophied.  Secondary  abscesses  and  fistulse  often  form,  as  in  case 
of  stricture  of  urethra.  Signs. — (1)  Constipation,  (2)  burning  pain  on 
passing  a  stool,  (3)  straining  at  stool,  (4)  blood  or  mucus  in  stools,  (5) 
patulous  anus,  (6)  "tape-like"  motions,  (7)  detection  of  a  stricture  by  dig- 
ital examination  or  by  a  bougie.  The  2d,  3d,  4th,  and  5th  signs  mark 
the  ulcerative  stage  ;  the  6th  sign  is  not  thoroughly  reliable.  Examine  very 
gently,  especially  if  using  a  bougie.  Roughness  may  do  fatal  damage.  Do 
not  mistake  for  stricture  obstruction  caused  by  mucous  folds  or  by  the 
pressure  of  pelvic  tumors.  Sooner  or  later  the  constipation  ends  in  com- 
plete obstruction,  which  may  come  on  with  great  suddenness.  In  advanced 
cases  the  general  health  breaks  down  under  the  influences  of  pain,  dys- 
pepsia, and  anxiety.  Treatment. — The  prime  agents  are  (1)  dilatation  by 
bougies,  (2)  incision.  The  latter  is  suited  only  for  traumatic  strictures 
close  to  the  anus.  Accessory  means  are,  rest  in  bed,  warm  water  enemata, 
regulated  diet,  morphia  suppositories  and  hip-baths.  Oil  the  bougies  well, 
pass  them  every  other  day,  gradually  increasing  the  size.  Patients,  when 
cured,  should  continue  to  pass  bougies  or  wax  candles  for  themselves,  either 
weekly  or  bi-weekly,  or  even  daily,  as  may  be  found  necessary.  When 
complete  obstruction  occurs  try  rest,  warm  hip-baths,  warm  oily  enemata 
and  purgatives.  The  surgeon  should  not  be  in  a  hurry  to  operate,  for  these 
cases  may  relieve  themselves  after  weeks  of  obstruction.  The  last  resource 
is  colotomy.  When  the  stricture  is  high  up,  give  the  enemata  thi'ough  the 
long  tube. 

Rectum,  Cancer  of. — Usually  scirrhus.     Pathology. — Originates  in  pro- 


200  RHEUMATISM. 

liferation  of  the  glands  of  the  mucous  membrane.  These  "grow  in  the 
shape  of  tortuous  and  branched  tubes  ;  the  cahbre  of  the  gland  is  often 
maintained  ;  and  they  fiU  with  mucus,  and  the  cylinder  cells  may  maintain 
this  form  and  become  very  large  "  (Billroth).  The  infiltration  and  indura- 
tion tend  to  surround  the  rectum  with  a  hard  ring.  "  Leaf-Hke  proUfera- 
tions  commence  close  above  the  sphincter  ani."  Ulceration.  "Inguinal 
and  retroperitoneal  glands  affected  rarely  and  late."  Ulceration  may  lay 
open  bladder,  lu-ethra,  vagina,  peritoneum,  hip-joint,  etc.  Symptoms. — At 
first,  discharge  of  bloody  mucus,  and  either  constipation  or  diarrhoea.  De- 
fecation becomes  more  and  more  painful.  Hemorrhage  becomes  more 
serious.  Digital  examination  usually  reveals  the  hard,  nodular  ring,  and 
perhaps  tdceration.  Diagnosis. — At  first  from  hemorrhoids,  a  Httle  later 
from  simple  stricture.  Usually  settled  by  digital  examination.  Treatment. 
— 1,  Palliative  ;  2,  radical.  1.  Palliative.  Anodynes,  e.g.,  morphia  sup- 
positories ;  afterward,  morphia  subcutaneously  or  by  the  mouth.  Some- 
times gentle  aperients,  wai-m  water  enemata.  Enemataof  cujDri  sulph.  and 
opium  or  of  zinci  chlor.  (gr.  j.-ij.  to  3  j.  aquae)  may  check  foul  discharges. 
Obstruction  or  extreme  pain  in  defecation  may  demand  colotomy.  2. 
Radical.  Excision  of  rectum  for  cancer  has  usually  been  condemned  on  ac- 
count of  the  risk  of  dangerous  hemorrhage,  and  of  opening  the  peritoneal 
cavity.  But  there  are  good  reasons  for  taking  an  opposite  view,  e.g.,  the 
neighboring  glands  are  not  secondarily  affected  at  an  early  stage.  Subject 
fully  discussed  by  W.  H.  Cripps  ("Cancer  of  the  Kectum  "). 

Rectum,  Polypus  of. — Usually  occurs  in  children,  is  adenomatous  in 
structure,  apt  to  signify  its  presence  by  occasional  hemorrhages,  and  may 
be  snipped  off  with  scissors.  In  exceptional  cases  a  ligature  may  be  con- 
sidered necessary. 

Rectum,  Malformations  or. —  Vide  Anus,  Imperforate. 

Rectum,  Injuries  of. — Causes. — IMay  be  classed  as  follows  :  (1)  falls  on 
sharp-pointed  objects,  e.g.,  spikes ;  (2)  sharp  bodies  swallowed,  e.g.,  fish- 
bones ;  (3)  objects  wilfully  inserted  ;  (4)  obstetric  processes ;  (5)  surgical 
operations  on  neighboring  parts.  The  first  class  usually  recover  thor- 
oughly, unless  fatal  tln:ough  comphcation  with  injuiy  to  more  serious 
parts,  such  as  the  peritoneum.  The  causes  of  the  2d  and  3d  class  re- 
quire immediate  removal  with  the  aid  of  fingers,  forceps,  speculum,  plenty 
of  oil,  etc.  The  3d  and  4th  class  of  cases  are  apt  to  produce  troublesome 
fistulse.  They  should  be  treated  with  as  little  delay  as  possible.  Vide 
Vaginal  Fistula. 

Rheumatism. — A  name  applied  almost  indiscriminately  by  thepubhc 
to  painful  non-traumatic  affections  of  the  joints  and  muscles,  more  espe- 
cially when  chronic.  The  form  called  "  rheumatic  gout "  chiefly  concerns 
the  surgeon.  He  terms  it  chronic  rheumatic  {or  rheumatoid)  arthritis. 
Causes. — Predisposing  influences  are  mal-nutrition,  poverty,  approach  of 
old  £ige,  male  sex.     Exciting  cause  usually  unknown.     Sometimes  injuiy, 


EHEDMAIISM.  201 

or  disordered  menstruation.  Symptoms. — Pain  in  the  aflfected  joint,  ag- 
gravated by  wet  or  cold  weather  and  by  exercise.  Stiffness.  Wasting  of 
muscles  which  act  on  the  joint,  e.g.,  of  glutei  and  hamstrings  in  chronic 
rheumatic  arthritis  of  hip.  Dry  crepitation  when  the  joint  is  moved. 
Eventually,  more  or  less  enlargement  of  the  bones  of  the  articulation. 
Thickening  of  the  ligaments.  Stiffness  may  proceed  to  anchylosis.  When 
the  hip  is  affected  shortening  takes  j)lace  sooner  or  later  from  absoi-ption  of 
head  of  thigh-bone.  Pelvis  becomes  obhque  ;  foot  is  either  everted  or  in- 
verted. When  the  temporomaxillary  joint  suffers,  dislocation  of  one  or 
both  sides  of  jaw  forward  may  result  from  destruction  of  eminentia  articu- 
laris.  Prognosis. — Progress  of  disease  usually  not  uniform,  but  effected  by 
recurrent  attacks  with  intervals  of  comparative  comfort.  But,  unfortu- 
nately, the  joints  do  not  retui-n  to  the  normal  state  in  these  intervals.  Re- 
covery almost  impossible.  No  direct  danger  to  life.  Bihroth  says : 
"  When  you  have  such  a  patient  to  treat,  arm  yourself  with  patience,  and 
be  not  surprised  if  he  consults  first  one  and  then  another  physician,  and 
finally  all  the  quacks  about,  and  lastly,  blames  you  foi*  the  origin  and  ex- 
tent of  his  disease."  Diagnosis. — From  (1)  scrofulous  arthritis,  (2)  gout, 
(3)  dislocation  from  injury.  Compare  with  symptoms  as  given  elsewhere. 
Particularly  consider  history  and  course  of  disease,  as  well  as  age  and  cii'- 
cumstances  of  patient.'  Pathology. — Begins  by  a  fibrillous  degeneration 
of  the  cartilages.  "In  some  places  it  becomes  nodular,  then  rough  on  the 
surface,  may  be  pulled  into  filaments,  and  when  the  disease  is  far  ad- 
vanced it  is  altogether  absent  in  places,  leaving  the  bone  exposed,  quite 
smooth,  and  polished  "  (Billroth).  Cartilage-cavities  enlarged  and  con- 
taining increased  numbers  of  new  cartQage-cells.  The  bone,  devoid  of 
cartilage,  compact,  and  polished  by  friction,  is  termed  "eburnated." 
"  Stalactitic  "  formation  of  osteophytes  in  immediate  neighborhood  of  above 
changes.  Bone  being  absorbed  in  one  place  and  formed  in  another,  situa- 
tion of  a  joint  may  shift  considerably.  Synovial  membrane  thickened, 
slightly  vascular,  tufts  elongated.  Separate  ossifications  near  the  joint 
(additamentaiy  bones).  New  bone  always  compact.  Muscles  of  affected 
joint  tend  to  contract.  Joints  tend  toward  a  state  popularly  described 
as  "drawn  up;"  witness  rheumatic  fingers  of  old  people.  Treatment. — 
Meant  rather  to  arrest  or  to  palliate  than  to  cure  the  disease.  Improve  the 
diet.  Remove  from  wet  and  cold  localities.  Clothe  in  flannel.  Frictions 
with  stimulating  hniments.  "Shampooing."  Douching  with  alternately 
very  hot  and  cold  water.  India-rubber  bandages.  Combinations  of  warm 
stomachics,  diaphoretics  and  mild  purgatives,  e.g.,  rhubarb,  ginger,  sul- 
phur, mezereon,  sassafras,  cream  of  tartar,  etc.  Iodide  of  potassium,  es- 
pecially when  pain  is  worse  at  night.  Chloral  and  pot.  bromid.  when  pain 
is  very  severe.     Acta?a  racemosa  (15  to  30  minims  of  tinctvire  three  times  a 

'  See,  in  Appendix,  Charcot's  Joint  Disease. 


202  EICKETS. 

day).  Residence  at  certain  watering-places,  e.g.^  Buxton,  Harrogate,  and 
Aix-la-Chapelle.  Leather  or  even  plaster-of-Paris  supports  useful  in  some 
cases  of  rheumatic  knee-joint.     Treat  menorrhagia,  if  present. 

Rhinoscopy. — Examination  of  nares  by  aid  of  the  laryngeal  mirror 
turned  upward  in  pharynx.  Difficult.  Natural  Causes  of  Difficulty. — 1, 
Irritability  of  fauces,  and  of  posterior  wall  of  pharynx ;  2,  enlarged  ton- 
sils and  uATila  ;  3,  insufficient  distance  between  uvula  and  posterior  wall 
of  pharynx.  Rules. — Same  as  those  for  Laryngoscopy  {quod  vide),  up  to 
Rule  6.  Rule  7.  Allow  patient's  tongue  to  remain  at  rest  and  untouched  in 
the  mouth.  8.  Hold  mirror  like  a  pen  and  with  the  reflecting  surface  up- 
ward. 9.  Let  its  shank  rest  hghtly  on  the  dorsum  of  the  tongue  ;  but  be 
very  careful  not  to  touch  the  base  of  the  tongue:  Shift  the  mirror  slightly 
to  right  or  left  of  uvula,  according  to  which  side  it  is  desired  to  examine. 
10.  Direct  patient  to  exhale  quietly  and  continuously  by  the  nostrils. 

Rickets. — Rachitis.  A  disease  of  early  childhood,  manifested  chiefly 
by  abnormal  softness  of  the  bones  and  consequent  defoiTnity,  and  by  back- 
ward development  of  the  teeth.  Causes. — Improper  feeding  in  infancy, 
especially  giving  young  infants  farinaceous  food  to  supplement  a  scanty 
supply  of  milk.  Other  bad  hygienic  conditions  probably  assist.  Signs. — 
At  first  the  little  patient  often  has  diarrhoea.  He  shrinks  from  being 
touched  ;  for  movement  is  painful.  Head  perspires.  Kicking  off  bed- 
clothes at  night.  Backward  dentition.  Laryngismus  stridulus.  Emacia- 
tion. The  above  symptoms  are  entirely  or  partially  absent  in  older  chil- 
dren. Disease  usually  commences  in  second  year.  The  infant  ceases  to 
walk  when  disease  is  at  its  height.  Deformity  of  chest  (pigeon-breast) 
now  takes  place.  Bow-legs,  knock-knees,  curvature  of  spine  (lateral  and 
antero-posterior),  as  well  as,  though  more  rarely,  pelvic  deformities,  occur 
when  the  patient  walks  about  again.  "  Beading  "  of  junctions  of  ribs  with 
costal  cartilages.  Enlargement  of  wrists,  knees,  and  ankles.  Fontanelles 
remain  open.  Head  grows  too  fast,  face  too  slow ;  hence  projecting  brows. 
Large  beDies  ; '  frequently  enlargements  of  Hver  and  spleen.  Bronchitis. 
The  subjects  of  rickets  in  childhood  will  not,  in  later  life,  attain  normal 
height.  Pathology. — IVIineral  constituents  of  bone  not  deposited  in  normal 
amount ;  but  animal  portions  grow  normally.  Hence  the  bones  soften, 
lacunae  enlarge,  periosteum  and  epiphyseal  cartilages  proliferate  ;  and,  as 
ossification  does  not  keep  pace  with  this,  long  bones  are  apt  to  bend  be- 
neath the  weight  of  the  body,  especially  at  the  junction  of  their  epiphyses 
with  their  shafts.  For  similar  reasons  the  growing  brain  forces  apart  the 
cranial  bones  and  keeps  open  the  fontanelles.  These  changes  near  the 
epiphyses  account  for  the  beaded  ribs,  the  enlarged  wrists,  and  the  de- 
formed knees  and  shins.  Also  general  thickening,  with  partial  thinning  of 
cranial  bones.     When  the  rachitis  disappears,  leaving  a  bent  long  bone, 

>  An  early  sign  of  great  value  (Clement  Lucas). 


SALIVARY    CALCULUS.  203 

the  concavity  of  the  curved  bone  is  eventually  strengthened  by  deposit  of 
a  ridge  of  compact  bone.  Rachitic  pelves  are  usually  flattened  antero- 
posteriorly.  Femora  curve  forward.  Tibije  and  fibulae  usually  bend  for- 
ward and  outward  (chiefly  at  jvmction  of  lower  epiphyses).  Spine  aflfected 
with  general  posterior  curvature  in  early  infancy,  with  lumbar  lordosis  in 
early  childhood,  and  occasionally  with  lateral  curvature.  Thorax — "pigeon- 
breasted."  Biagnosis. — Quite  easy,  except  in  early  stage.  Prognosis. — 
Sometimes  fatal  to  very  weakly  infants.  Recovery  usual,  but  rarely  with- 
out residual  deformity.  Treatment. — Correct  diet.  Plenty  of  milk.  Suffi- 
cient animal  food.  Cod-liver  oil.  Syrup  of  phosphates  of  iron  and  lime. 
Parrish's  chemical  food.  Vinum  ferri.  Cold  sponging  and  dry  rubbing. 
Fi'esh  air.  Splints  and  other  mechanical  contrivances  to  correct  de- 
formities. In  severe  cases,  osteotomy,  or  forcible  straightening  of  limbs 
under  chloroform.  Keep  a  young  rickety  child  ofif  its  feet  as  much  as  pos- 
sible without  depriving  it  of  fresh  air  and  exercise.     Sleep  on  a  mattress. 

Sacro-iliac  Disease.  —  Causes. —  Either  struma  or  injury,  or  both 
together.  Symptoms. — Local  pain  and  tenderness.  Pain  during  defeca- 
tion, sometimes  also  during  mictnrition.  Peculiar  posture  (vide  figures  in 
Sayre"s  "  Orthopaedic  Surgery,"  p.  333).  Patient  bends  his  body  over  fi-om 
the  aflfected  side,  "  for  the  purpose  of  removing  pressure  from  the  diseased 
structures  by  bringing  the  weight  of  the  limb  to  bear  upon  the  ilium." 
Hence  obliquity  of  the  pelvis  and  apparent  lengthening  of  limb  on  side  of 
disease.  When  abscess  forms,  it  may  appear  either  over  the  articulation, 
or  in  the  buttock,  loin,  groin,  or  even  rectum.  Diagnosis. — From  neural- 
gia, sciatica,  and  Pott's  disease,  but,  above  all,  from  hip  disease.  In  sacro- 
iHac  disease,  if  the  pelvis  be  firmly  fixed,  the  hip-joint  can  be  moved  nor- 
mally and  painlessly.  In  sufficiently  advanced  cases,  the  pelvis  can  be  seen 
to  be  deformed  ;  and  when  abscess  has  opened,  a  probe  will  often  reach 
dead  bone.  Sayre's  vertebrated  probe  may  be  useful.  When  pelvis  is 
not  fixed,  either  lateral  compression  of  trochanters  or  abduction  of  thigh 
causes  pain.  Prognosis  bad.  Treatment. — Rest,  extension  and  counter- 
extension.  Sayre  puts  a  thick-soled  shoe  on  the  foot  of  sound  side  so  that 
the  afiected  limb  swings  free  of  the  ground  when  the  patient  moves  out  of 
doors  on  crutches.  Before  suppuration  takes  place,  use  counter-irritation, 
especially  the  actual  cautery.  Dead  bone,  if  detected  by  probe,  should  be 
removed  if  possible.  Cod-liver  oil,  iron.  High,  dry,  and  healthy  locali- 
ties. 

Salivary  Calculus. — A  concretion  sometimes  obstructs  a  salivary 
duct.  Slit  up  the  duct,  if  necessary,  and  remove  it.  May  cause  swelling 
of  gland.     Ducts  usually  affected  are  the  sublingual  or  submaxillary. 

Salivary  Fistula  (1)  from  obstructed  duct.  Treatment. — Establish  an 
opening  into  the  mouth  by  passing  a  seton  right  through  the  fistula  into 
the  mouth  and  tying  its  two  ends  together.  Part  of  the  cheek  is  thus,  of 
course,  enclosed  in  the  loop.     When  an  opening  into  the  mouth  is  thus 


204  SCROFULA. 

kept  open  for  ten  days,  endeavor  to  close  the  external  opening  by  cauteri- 
zation, unless  it  close  spontaneously.  (2)  Salivarj'  fistula  from  abscess  in  a 
gland  is  difficult  to  cure.     Try  cauterization. 

Sarcocele. — See  Testicle. 

Sarcoma. — See  Tumors. 

Scalp,  Injuries  of. —  Vide  Head. 

Sciatica. — Neuralgia  of  great  or  of  lesser  sciatic  nerve.  Causes. — (1) 
Catching  cold  ;  (2)  pressure  of  hai*dened  faeces  in  rectum  or  of  pelvic  tu- 
mors ;  (3)  peripheral  irritations,  e.g.,  inflamed  corns  ;  (4)  many  cases  are  of 
qxiite  obscxu'e  origin.  Always  bear  in  mind  that  sciatic  neuralgia  may  be 
only  a  sign  of  some  more  serious  disorder.  Diagnose  from  hip  and  from 
sacro-iliac  disease.  Treatment. —  Vide  Neuealgia.  In  obstinate  cases  try 
cautery  (Corrigan's  button),  or  even  "nerve-stretching."  Purgatives,  qui- 
nine. Iodide  of  potassium.  Morphia  injections.  BUsters.  Electricity. 
For  Pathology,  etc.,  of  Sciatica  vide  Neuralgia. 

Scrofula. — Definition. — A  diathesis  rather  than  a  disease.  Its  charac- 
teristics are  neatly  given  by  Billroth  as  follows:  "Exists  chiefly  during 
childhood,  though  more  advanced  ages  are  not  free  fi'om  it."  '  "  Persons 
with  this  diathesis,  especially  children,  are  greatly  disjjosed  to  chronic  in- 
flammatory swellings  of  the  lymphatic  glands,  even  after  inconsiderable 
irritations,  to  certain  inflammations  of  the  skin  (eczema,  impetigo),  espe- 
cially of  the  face  and  head,  to  catarrhal  inflammations  of  the  mucous  mem- 
branes, especially  of  the  conjunctiva,  more  rarely  of  the  intestinal  canal 
and  respiratory  organs,  to  chronic  inflammations  of  the  periosteum,  and  of 
the  synovial  membranes  of  the  joints."  Formerly  the  condition  called 
"tuberculosis"  was  unanimously  included  in  the  term  scrofula.  Majority 
of  modern  pathologists  differentiate  the  two,  while  acknowledging  the  fre- 
quent origin  of  the  former  from  the  products  of  chronic  inflammations 
induced  by  the  latter.  Causes. — Inheritance.  Unfavorable  conditions  of 
life  (?),  e.g.,  low,  damp  dwelling,  want  of  light,  insufficient  food,  mental 
depression.  Attacks  of  acute  infectious  fever,  especially  measles.  Pathol- 
ogy and  Symptoms. — See  under  head  of  Glands,  Chronic  Disease  of  ;  Ul- 
cers, Scrofulous  ;  Joints,  Chronic  Disease  of  ;  Ophthalmia,  Strumous,  etc. 
Chronic  inflammations,  the  result  of  scrofula,  are  indolent  and  slow  to  dis- 
perse. They  tend  greatly  to  suppuration  and  caseous  degeneration.  Cer- 
tain general  appearances  of  the  person  are  described  as  scrofulous  types, 
especially  two,  viz.:  (1)  thick  lips,  muddy  skin,  coarse  featui'es,  pot  belly, 
flabby  muscles,  often  with  tendency  to  fatness ;  (2)  fair,  thin,  clear  skin, 
long  eyelashes,  fine  hair,  pearly  teeth,  bright,  refined,  "delicate"  look. 
These  so-called  typical  appearances  are  of  very  doubtful  diagnostic  value. 
Dyspepsia  very  common.  Diagnosis. — The  great  question  is,  "  What  justi- 
fies the  svirgeon  in  terming  a  certain  patient  '  scrofulous  ? ' "    The  answer 

'  Bead  Paget  on  Senile  Scrofula,  in  his  Clinical  Lectures. 


SCROTUM,    DISEASES    OF.  205 

usually  depends  greatly  on  the  surgeon's  individuality.  By  some  authorities 
such  a  thing  as  scrofula  is  hardly  admitted  to  exist ;  all  the  ajDpearances 
associated  with  its  name  being  referred  to  local  or  special  causes.  Usually, 
any  such  morbid  manifestations  as  have  been  catalogued  above,  if  the 
known  exciting  cause  is  trivial,  or  if  no  cause  at  all  be  known,  are  regarded 
as  scrofulous  ;  and  especially  if  more  than  one  such  aft'ection  attack  the 
same  individual,  and  if  he  present  the  peculiarities  of  personal  appearance 
mentioned  above.  Prognosis. — Under  treatment,  with  moderately  favor- 
able conditions,  the  individual  manifestations  usually  disappear,  often 
leaving  ugly  scars.  But  the  diathesis  almost  always  remains.  It  may  lie 
latent  throughout  a  vigorous  manhood,  and  reappear  in  a  decrej)it  old  age. 
Danger  of  tuberculosis  supervening :  said  to  be  greatest  in  fair,  delicate, 
or  "  sanguine  "  type  of  the  scrofulous.  Treatment. — Hygienic  and  medical, 
general  and  local.  Hygienic  requires  the  various  conditions  usually  con- 
sidered "  strengthening,"  fi-esh  air,  good  food,  dry  lodging,  daylight,  cheer- 
ful occupation,  flannel  clothing,  moderate  exercise.  Cleanliness  of  head 
and  skin.  Strict  attention  to  each  trivial  ailment.  Medical  treatment  is 
(1)  antidyspeptic,  and  (2)  tonic  and  nutritive.  Tongue,  stomach,  and 
bowels  must  be  attended  to  on  general  principles.  Gregory's  powder  and 
hydr.  c.  cret.  often  useful,  especially  in  children.  Sod;^  bicarb,  (grs.  x.- 
XV.)  ter  die  in  inf.  calumbae  just  before  meals.  Cod-liver  oil  is  the  remedy. 
Give  it  after  meals,  3  j.  bis  die,  increased  gradually  up  to  §  j.  ter  die.  Occa- 
sionally suspend  its  administration  if  it  disagree  with  stomach.  Small 
doses  of  nitric  acid  and  strychnine  useful  adjuncts  (Williams  quoted  by 
Savory).  Iron,  ammonio-tartrate,  citrate,  fresh  carbonate,  vinum  ferri 
(iodide  of  iron,  in  fat,  flabby  children).  Iodides  sometimes  mischievous 
if  fever  be  present.  Mineral  acids.  Quinine,  tinct.  cinchonse  co.  Pan- 
creatic emulsion.  Change  to  a  new  chmate,  which,  whether  warm  or  tem- 
perate, should  certainly  be  dry ;  English  watering-places,  Margate,  etc.  ; 
Madeira,  sea  voyage.  Local  treatment  is  given  under  special  heads.  In 
old  age,  "iron,  cod-liver  oil,  sea  air,  etc.,  of  little  potency.  Best,  warmth, 
and  good  food  more  important"  (Paget). 

Scrotum. —  Wounds  heal  very  readily.  Bruises  often  produce  hcemato- 
cele,  quod  vide. 

Scrotum,  Diseases  of. — The  scrotum,  consisting  as  it  does  chiefly  of 
skin  and  cellular  tissue,  is  liable  to  the  ordinary  cutaneous  diseases.  More- 
over, inside  its  serous  lining  are  found  hydroceles,  hsematoceles,  hernias, 
and  diseases  of  the  testicle.  Certain  affections  of  the  scrotum  present  spe- 
cial features  worthy  of  note.  The  chief  of  these  are  (1)  inflammation,  (2) 
elephantiasis,  (3)  epithelioma. 

Scrotum,  Inflammation  of,  is  remarkable  for  the  amount  of  oedema 
which  accompanies  it,  for  its  usually  difiiise  character  (a  kind  of  erysipe- 
las), and  for  its  frequently  ending  in  partial  sloughings.  Its  usual  causes 
are  extravasation  of  urine,  or  continued  irritation  of  some  trivial  local  af- 


206  SEPTICAEMIA. 

fection.  Prognosis  in  every  way  good,  except  in  bad  cases  of  extravasation. 
Treatment. —  Vide  Erysipelas,  and  Urine,  Extravasation  of. 

Scrotum,  Elephantiasis  of. — A  cellulo-cutaneous  hypertrophy,  with  more 
or  less  oily  infiltration.  Very  rare  except  in  the  East  and  West  Indies,  in 
Egypt,  and  in  South  America.  Prime  cause  unknown.  Exciting  cause, 
occasionally  some  local  iiTitation.  The  tumor  may  even  attain  a  weight 
equal  to  that  of  all  the  rest  of  the  patient,  trunk  and  limbs  inclusive.  Sur- 
face sometimes  smooth,  sometimes  tuberculated.  Prognosis.  —  Steady 
growth.  Perhaps  eventually  death  from  supervening  ulceration.  Treat- 
ment.— Excision.  If  under  forty-two  pounds  in  weight,  try  to  dissect  out 
and  save  testicles  and  penis.     Danger  of  great  hemorrhage. 

Scrotum,  Epithelioma  of  (Chimney-sweep's  Cancer). — Chiefly  attacks 
chimney-sweeps.  Commences  as  a  wart  or  tubercle  "  oftenest  near  the 
lower  and  fore  part "  of  scrotum  (Humphry).  Structure  that  of  epithe- 
lioma elsewhere.  Treatment. — Excise.  Decidedly  enlarged  glands  in  gi-oin 
should  be  excised  too.  Very  Httle  tendency  to  affect  the  system,  but  great 
tendency  to  recurrence.  Ii'ritation  of  soot  has  been  known  to  produce 
epithehoma  on  hand  of  a  gardener. 

Scurvy. — Believed  to  be  a  blood  disease.  Causes. — Salt  meats.  Want 
of  fresh  meat  and  fi*esh  vegetables.  Subsidiary  causes  are  severe  cold,  and 
all  depressing  influences.  "  In  former  Ai'ctic  expeditions  scurvy  occurred 
in  men  who  indulged  to  excess  in  alcohol,  and  who  had  not  been  exposed 
to  the  deteriorating  conditions  that  existed  during  sledge-travelling." ' 
Morbid  Anatomy. — Extravasations  all  over  the  body,  beneath  skin,  in  se- 
rous cavities,  in  viscera,  and  in  intermuscular  spaces.  Extreme  emacia- 
tion. Ulcerations.  Symptoms  and  Course.  —  Premonitory  signs,  great 
lassitude,  pains  in  joints.  Then  appear  sore  mouth,  petechia,  and,  by 
and  by,  ulcers  and  blood-tumors.  Hemorrhages  of  various  kinds,  internal 
and  external ;  progressive  exhaustion.  Prognosis. — Fatal,  unless  the  causes 
be  removed.  Proper  treatment  rescues  very  bad  cases  indeed.  Treatment. 
— Vegetables.  Fresh  meat.  Lime-juice.  Best  attainable  hygienic  condi- 
tions. Treat  local  manifestations  on  general  surgical  principles.  Owing 
to  impossibility  of  melting  lime-juice  on  sledge  excursions  in  polar  regions, 
concentrated  lime-juice  lozenges  have  been  devised. 

Septicaemia. — A  disease  in  which  the  blood  is  poisoned  by  septic 
matter.  In  this  respect  it  does  not  differ  from  pyeemia,  and  many  if  not 
all  cases  of  surgical  fever.  Bryant  even  writes,  "  Surgical,  suppurative,  or 
traumatic  fever  ;  septicaemia,  ichorEemia,  puerperal  fever,  and  pyaemia,  may 
all  be  considered  as  so  many  different  names  for,  and  manifestations  of, 
one  condition,  blood-poisoning."  In  practice,  however,  "  surgical  fever," 
"  septicaemia,"  and  "pyaemia  "  are  not  considered  as  different  names  for  one 

'  Report  of  Committee  on  Scurvy,  in  Sir  George  Nares'  expedition,  quoted  by  Mr. 
H.  Leach. 


SHOCK,  207 

condition,  tliougli  it  is  difficult  to  define  the  limits  of  each.  I  have  most 
often  heard  surgeons  apply  the  term  septicaemia  to  acute  cases  in  which 
the  nervous  and  digestive  organs  were  the  seat  of  prominent  symptoms, 
while  there  was  an  absence  of  clear  signs  of  secondary  abscess.  Compare 
with  pyaemia.  Causes. —  Vide  Pyaemia.  Signs. — ^Apathetic  state  ;  rarely 
excitement.  Tongue  very  dry.  Speech  feeble.  No  appetite.  Either 
perspu-ation  or  dryness  of  skin.  Symptoms  often  bear  considerable  re- 
semblance to  those  of  typhus.  Urine  scanty.  Temperature,  at  first  high, 
tends  to  fall  as  death  approaches.  Occasional  extreme  rapidity  of  rise. ' 
Bed-sores  form  ;  urine  and  faeces  are  passed  in  bed.  Finally  collapse  and 
death.  The  elevation  of  temperature  is  often  slight,  especially  in  weak, 
old  people.  Chronic  blood  poisoning  is  more  likely  to  take  one  of  the 
forms  of  pyaemia  or  the  form  of  hectic  fever.  Pathology. — Condition  of 
the  blood  not  at  all  characteristic.  "If  we  have  not  seen  the  patient  dur- 
ing Ufe,  we  shall  often  examine  the  dead  body  in  vain  for  some  palpable 
cause  of  death"  (BiUroth).  Spleen  often  enlarged  and  softened,  rarely 
normal.  Liver  congested  and  very  friable.  "In  the  heart  the  blood  is 
lumpy,  half-clotted,  tarry,  and  rarely  firmly  coagulated,  buffy  ;  in  most 
cases  the  lungs  are  normal.  Where  the  course  of  the  affection  '  has  been 
very  long  (a  fortnight  or  more)  the  disease  shows  itself  mostly  by  exten- 
sive suppuration  of  the  cellular  tissue '  (near  the  wound),  '  with  more  or 
less  extensive  gangrene  of  the  skin'"  (Billroth).''  Prognosis  and  Treat- 
ment.—  Vide  Pv^ivnA. 

Shock.—  Causes. — Injuries,  especially  if  very  painful,  or  attended  with 
hemorrhage  ;  or  if  in  certain  localities,  e.g.,  abdominal  viscera,  testicles, 
and  the  larger  joints.  Mental  emotions.  When  an  injury  is  foreseen  and 
expected,  shock  is  more  severe  than  when  the  recipient  is  excited  and  care- 
less. Children  less  liable  than  adults.  But  acute  pain  readily  causes  col- 
lapse in  a  few  hours  in  children  (H.  Marsh).  Sigyis. — Pallor,  coldness, 
weakness,  even  amovmting  to  utter  prostration.  Consciousness  may  or 
may  not  be  seriously  aifected.  The  mind  may  be  clear,  and  yet  the  limbs 
but  little  sensitive  to  pain.  Temperature  actually  sinks  2°,  3°,  or  4",  or 
more  in  severe  cases.  Pulse  thread-like.  Kespiration  sighing.  Nausea, 
vomiting.  In  certain  cases  the  patient  is  noisy  and  delirious.  Generally 
he  is  either  quiet  or  wanders  slightly  in  his  mind.  Course. — Death  may 
result  almost  instantaneously,  even  when  the  prime  injiuy  is  apparently 
trifling.  This  is  most  common  in  injuries  to  the  abdominal  viscera.  But 
reaction  usually  occurs  in  a  few  hours,  and  is  frequently  excessive,  passing 
into  fever.  And,  again,  shock  may  endure  for  many  houi's,  and  at  last 
prove  fatal.      Pathology. —It  is  certain  that  paralysis  of  the  vaso-motor 

•  From  102.6  to  107  in  ten  minutes  in  a  case  under  Mr,  Bickerateth  (British  Medi- 
cal Journal,  1879). 

^  See  Microscopic  Organisms,  in  Appendix. 


208  SINUS. 

nerves,  probably  inhibitory,  is  an  essential  part  of  shock  ;  but  it  is  not  so 
certain  whether  it  is  universal  or  local.  Golz  showed  that  when  a  frog  is 
struck  on  the  abdomen,  its  heart  ceases  to  beat,  and  at  the  same  time  the 
portal  system  is  vastly  distended  with  blood.  He  supposes  the  former 
phenomenon  to  be  the  effect  of  the  latter,  and  the  two  together  to  account 
for  the  featiu-es  of  shock  ;  but  Moullin  argues,  and  with  reason,  that,  in 
shock,  there  is  primarily  a  far  more  general  inhibition  of  the  vaso-motor 
system.  Diagnosis  from  syncope,  the  result  of  hemon-hage. — When  the 
hemorrhage  is  internal,  this  diagnosis  may  be  impossible  at  first ;  but  in 
the  case  of  hemorrhage,  when  reaction  takes  place,  the  pallor  of  the  gums 
and  conjunctivae  persists.  Prognosis  depends  on  the  amount,  on  the  per- 
sistence, and  on  the  attendant  complications  of  the  attack.  A  particularly 
dangerous  condition  is  that  termed  "  prostration  with  excitement,"  in 
which  "the  languor  or  stupor  of  collapse  is  succeeded  by  restlessness, 
jactitation,  tremor,  and  twitchings  of  the  muscles,  precordial  anxiety, 
often  but  not  always  delirium  of  various  degrees"  (Savory).  Treatment. — 
Warmth,  hot  water  bottle  to  feet,  flanks,  and  epigastrium,  warm  affusion 
to  head.  Horizontal  position.  Frictions.  Stimulants  :  brandy,  ammonia. 
Do  not  pour  fluids  down  a  patient  unable  to  swallow.  Galvanism  to  prse- 
cordia.  Treat  hemorrhage  if  present.  Remembej  that  collapse  in  some 
cases  of  internal  hemorrhage  is  useful,  by  giving  time  for  nature  to  close 
the  bleeding  vessels.  In  such  cases  the  treatment  had  better  be  limited 
to  horizontal  posture,  strict  quiet,  external  warmth,  and  such  action  as  the 
bleeding  may  demand.  Transfusion.  When  reaction  has  commenced, 
food  must  be  given,  e.g.,  small  quantities,  fi'equently  repeated,  of  brandy 
and  egg  mixture,  milk,  and  strong  soup.  With  regard  to  operating  during 
shock,  the  surgeon  seldom  hesitates  now,  relying  upon  the  stimulating 
powers  of  eth'er  and  the  relief  from  pain  and  discomfort  which  follows 
the  removal  of  a  mangled  limb.  But  every  care  must  be  taken  to  prevent 
hemorrhage,  which  is  very  badly  borne  by  a  collapsed  patient. 

Sinus. — An  abnormal  passage  whose  length  decidedly  exceeds  its  di- 
ameter, and  which  is  not  a  healthy,  healing  wound.  Paget,  in  describing 
sinus  and  Jistula  together,  says  they  include  three  classes,  viz.  :  (1)  long, 
narrow,  suppui-ating  canals  ;  (2)  canals  giving  exit  to  unnatural  secretions 
{e.g.,  gastric  fistula,  bihai-y  fistula) ;  (3)  abnormal  apertures  between  mu- 
cous cavities  {e.g.,  vesico-vaginal  fistula).  He  goes  on  to  say  that  "  if  a  dis- 
tinction is  to  be  made  between  the  terms,"  "  sinus  "  shovild  be  applied  ex- 
clusively to  those  of  the  first  form,  in  which  the  canal  has  but  one  opening. 
To  thus  limit  the  term  "  sinus,"  would  be  to  differ  from  many  surgeons 
{vide,  e.g..  Pott's  chirurgical  works,  p.  590,  where  "  sinus "  means  either 
Wind  or  complete  fistula).  Causes. — Usually  (1)  abscess,  sometimes  (2) 
wound,  (3)  ulceration,  (4)  sloughing.  In  addition  to  these,  one  or  other  of 
the  following  secondary  causes  almost  essential,  viz.  :  (1)  presence  of 
dead  bone,  or  of  foreign  body,  (2)  some  mechanical  obstruction  to  the  free 


SPEEMATORRHCEA.  209 

discharge  of  pus,  (3)  the  occasional  passage  of  secretions  or  excretions 
into  the  sinus,  (4)  presence  of  diseased  glands  (strumous  or  otherwise). 
Passage  of  sinus  among  muscles  is  a  cause  which  may  be  classed  with  (2). 
Treatment. — Find  out  and  treat  cause.  Sayre's  vertebrated  probe  useful 
when  track  is  sinuous.  Remove  dead  bone,  etc.  Slit  up,  if  situation  of 
sinus  permits.  Injections  of  iodine,  tannic  acid,  Condy,  etc.  Antiseptic 
bougies.  Pressure.  Drainage  by  passing  a  tube  nearly  to  the  bottom  of 
the  sinus.  This  can  be  combined  with  injection.  Withdraw  slightly  each 
day.  Cautery,  especially  galvanic  or  benzohne  cautery.  If  the  sinus  pass 
among  muscles,  and  cannot  be  slit  up,  the  attachments  of  these  muscles 
should  be  fixed  by  bandages,  etc. 

Skin,  Diseases  of. — See  Eczema,  Ecthyma,  Psoriasis,  Corns,  Warts, 
Elephantiasis,  Scabies,  etc.,  etc.  ;  only  the  commonest  forms  are  noticed 
in  this  work. 

Skin,  Transplantation  of. — (1)  Minute  pieces  of  epidermis,  which  should 
include  the  youngest  layers,  namely,  those  next  the  true  skin,  are  shaved 
or  cut  off  and  placed  upon  the  surface  of  a  healing  ulcer,  in  order  that 
they  may  there  form  nuclei  whence  cicatrization  may  spread.  (2)  Skin  is 
sometimes  only  partially  severed  from  its  connections,  and  then,  with  the 
circulation  still  active  within  it,  transferred  to  the  raw  surface  of  another 
part.  In  this  way,  e.g.,  gaps  in  the  skin  of  the  chest  may  be  filled  in  from 
that  of  the  arm.  Of  course  the  arm  has  to  be  bound  to  the  bosom  until 
the  skin  has  formed  adhesions  in  its  new  site.  (3)  Pieces  of  skin,  even  of 
considerable  size,  thoroughly  cleaned  free  of  subcutaneous  tissue,  have 
been  successfully  transplanted  without  any  pedicle  being  left  attached  to 
them  [vide  papers  by  Wolff  of  Glasgow).  In  the  first  (far  the  common- 
est) method  it  is  enough  to  place  a  small  piece  of  gutta-percha  tissue  over 
each  transplanted  fragment,  and  to  cover  with  water-dressing. 

Skull,  Injuries  of. — See  Head. 

Sloughing. — See  Gangrene. 

Snake-bites. — See  Bites  of  Snakes. 

Snuffles. — See  Syphilis,  Congenital.     (In  Appendix.) 

Spectacles. — See  Eyes.      (In  Appendix.) 

Spermatic  Cord. — Frequently  affected  secondarily  to  the  testicle,  e.g., 
by  cancer.  Subject  independently  to  hydrocele  {quod  vide),  haematocele, 
lipoma,  neuralgia,  etc. 

Spermatorrhoea. — An  abnormal  discharge  of  semen.  A  chronic  dis- 
order. Nocturnal  emissions,  if  not  oftener  than  once  a  fortnight,  scarcely 
considered  abnormal.  Cause. — Almost  always  masturbation.  Synvptoms. 
— Niemeyer  describes  four  classes  of  cases  :  (1)  persons  who  have  un- 
natural emissions  simply  because  they  continue  to  masturbate.  To  their 
doctor  they  describe  such  symptoms  as  "  nervousness,"  lassitude,  palpita- 
tion, various  exaggerated  pains  about  the  genitalia,  etc.  They  readily  con- 
fess that  they  have  practised  self-abuse,  but  pretend  they  have  given  it  up. 

14: 


210  SPINE,    DISEASES    OF. 

(2)  Kobust-looking  persons  who  have  really  given  up  their  bad  habits  and 
recovered  their  general  health,  but  who  are  sexual  hypochondriacs  for  some 
other  reason.  (3)  Weakly,  aneemic  persons,  who  have  never  masturbated, 
and  in  whom  ordinary  and  not  frequent  wet-dreams  produce  dulness  and 
lassitude.  (4)  True  cases  of  spermatorrhoea,  in  which  exhaustion,  etc.,  are 
really  produced  by  too  frequent  seminal  losses.  Their  symptoms  are  as 
foUow :  sadness,  disHke  to  work,  lassitude,  inattention,  cowardice,  trem- 
bUngs,  noises  in  the  head,  dizziness,  neuralgic  pain  in  back  of  head,  etc. 
Resemblance  to  hysteria.  In  these  cases  especially,  semen  often  flows 
away  with  the  urine  or  during  defecation.  But  note,  the  latter  symptom 
is  not  uncommon  in  healthy  men.  Distinguish  between  mere  mucus  and 
semen  by  the  microscope,  which  in  the  latter  case  should  discover  sper- 
matozoa. Pathology  of  the  last  form  (true  spermatorrhoea). —  Probably  a 
state  of  chronic  congestion  and  relaxation  about  the  prostatic  part  of  the 
urethra  and  the  openings  of  the  seminal  ducts,  added  to  an  undue  irrita- 
bility of  the  nervous  system  ;  in  fact,  a  condition  similar  to  the  hysteria 
caused  in  women  by  ulceration  of  the  os  uteri.  Prognosis. — Cure  difficult 
in  many  cases,  (1)  because  patient  will  not  refrain,  from  bad  habits,  either 
of  self-abuse,  of  alcohol- drinking,  of  excessive  meat-eating,  of  lying  in  bed 
in  the  morning,  or  of  sedentary  employment  without  proper  outdoor  ex- 
ercise ;  (2)  because  of  chronic  nature  of  ailment.  Treatment. — Insist  upon 
total  abstinence  from  the  vices  just  enumerated.  The  difficulty  of  stopping 
masturbation  is  well  known.  It  seems  to  me  that  the  most  I'ational  indi- 
cation is  to  be  derived  from  its  being  essentially  a  secret  vice,  practised 
chiefly  or  entirely  in  bed.  A  patient  who  eventually  lost  his  reason 
through  it,  even  when  the  habit  was  inveterate,  always  ceased  from  it  so 
long  as  his  attendant  slept  in  the  same  bed  with  him.  The  sex  of  the  bed- 
fellow does  not  affect  the  result,  therefore  marriage  may  be  advisable. 
Occasional  intercourse  with  lewd  women,  which  has  been  recommended 
even  by  physicians,  is  of  somewhat  doubtful  value,  and  of  course  morally 
objectionable.  Cold  hip-baths  in  the  morning.  Patient  should  get  up  and 
empty  his  bladder  as  soon  as  ever  he  awakes  in  the  morning,  even  if  he 
gets  into  bed  again.  Hard  mattress.  No  supper  ;  no  tea  in  evening.  At- 
tend to  digestion.  Eevalenta  Arabica,  or  fish  and  milk  diet  may  be  useful. 
Keep  bowels  open.  Blisters  to  perinjEum.  When  varicocele  or  relaxed 
genitalia  coexist,  patient  should  wear  my  suspensory  bandage,  made  by 
Arnold,  of  West  Smithfield.  If  improvement  be  not  satisfactory,  cauterize 
prostatic  part  of  urethra  with  Lallemand's  "  porte-caustique."  Repeat 
three  or  four  times  if  necessary.  Drugs  given  are  (1)  belladonna,  gr.  ^  of 
extract,  -j-  zinci  sulph.,  gr.  iiss.,  ter  die  ;  (2)  bromide  of  potassium.  Phos- 
phorus, quinia,  strychnia,  iron,  and  cantharides  are  given  when  sperma- 
torrhoea is  associated  with  impotence. 

Spine,  Diseases  of. — Term  "  spinal  disease  "  sometimes  restricted  to 
caries.     Angular  curvature  is,  of  covirse,  always  described  with  caries.   Be- 


SPINE,    DISEASES    OF.  211 

sides  the  above,  there  are  lateral  and  antero-posterior  curvatures,  hyster- 
ical and  rheumatic  affections,  and  spina  bifida. 

Angular  Curvature  ;  Pott's  Curvature  of  the  Spine  ;  Caries  of  the 
Spine. — These  three  terms  are  not  quite  synonymous,  but  they  are  con- 
stantly used  as  such.  Caries  pi'e cedes  and  causes  the  curvature.  Causes. — 
Scrofulous  constitution — male  sex  in  children,  female  sex  in  young  adults, 
rare  in  more  advanced  life.  Often  a  history  of  a  fall  or  blow. '  Whooping- 
cough.  Pathology. — Commences  either  as  simple  caries,  or  as  tuberculous 
disease  of  the  vertebral  bodies,  or  as  inflammatory  softening  of  the  inter- 
vertebral cartilages.  As  the  destructive  process  proceeds,  two  striking  ef- 
fects almost  always  result,  viz.  :  (1)  a  posterior  angular  projection  of  the 
corresponding  spinous  processes  ;  (2)  less  frequently,  formation  of  abscess. 
As  many  as  six  or  eight  vertebral  bodies  have  been  known  to  break  down  : 
usually  only  two  or  three  are  involved.  Laminse,  spines,  and  articular  pro- 
cesses escape  ;  but  there  is  a  great  tendency  for  them  to  anchylose  together. 
Collapse  of  the  spine  anteriorly  at  the  seat  of  caries  causes  the  posterior 
angular  projection.  Compensatory  curvatures  in  other  regions  of  the  spine. 
Curvature  in  lumbar  disease  occasionally  lateral  as  well  as  antero-posterior. 
Middle  and  lower  dorsal  regions  commonest  seats  of  caries.  Spinal  cord 
is  (1)  so  small  as  compared  with  diameter  of  spinal  canal,  and  (2)  so  well 
protected  by  its  membranes,  that  it  is  usually  unaffected ;  but  in  many 
cases  paraplegia,  usually  motor  and  partial,  and  often  temporary,  occurs. 
The  immediate  cause  is  probably  iuflammatoiy  effusion,  or  else  pressure 
from  a  sudden  rapid  increase  of  the  deformity.  Even  aorta  may  be  com- 
pressed between  the  diseased  vertebrae  as  the  latter  fall  together.^  Abscess 
usually  "  psoas  "  in  disease  of  dorsal  or  lumbar  vertebrae.  Frequently  lum- 
bar. In  cervical  caries,  abscess  usually  presents  toward  side  of  neck, 
sometimes  in  pharynx  (retro-pharyngeal  abscess).  But  the  pus  may  bur- 
row in  various  directions,  e.g.,  into  pelvis,  buttocks,  abdominal  wall  above 
Poupart's  hgament,  and  from  the  neck  into  the  thorax.  Psoas  abscess 
passes  down  in  the  sheath  of  the  psoas  muscle,  forming  a  swelling  first  in 
the  inguinal  region  of  the  abdomen,  and  next  in  the  thigh  beneath  Pou- 
part's ligament,  toward  the  outer  rather  than  the  inner  side  of  Scarpa's 
triangle.  It  may  extend  downward  much  farther,  and  occasionally  turns 
outward  or  inward.  Sometimes  it  is  double,  i.e.,  passes  down  the  sheaths 
of  both  psoas  muscles.  Lumbar  abscess  perforates  the  quadratus  lum- 
borum,  and  presents  in  the  loins  immediately  external  to  the  elector  spinae. 
Spinal  abscess  may  (1)  be  absorbed,  or,  (2)  after  a  more  or  less  chronic 


'  See  a  paper  by  Mr.  Willett  in  St.  Bartholomew's  Hospital  Reports,  vol.  xiv., 
p.  325.  Out  of  60  cases,  the  assigned  cause  was  a  blow  or  fall  in  21  cases,  previous 
illness  in  5,  and  cause  unknown  in  the  remaining  34  ;  14  were  strumous  subjects ;  that 
is,  were  sickly,  delicate  persons  of  strumous  aspect. 

^  See  Goodhart,  Pathological  Transactions,  1878. 


212  SPINE,    DISEASES    OP. 

course,  burst,  or  (3)  be  opened  by  the  surgeon.  When  opened,  unless 
antiseptic  j^recautions  be  taken,  hectic  fever  supervenes.  When  anchylosis 
tates  place,  even  the  laminae  and  spinous  processes  of  adjacent  vertebrse 
unite.  Si/mj)ioms. — In  children,  the  first  sign  observed  is  generally  a 
prominence  of  one  or  more  vertebral  spines  ;  but  if  the  lumbar  region  be 
affected,  no  prominence  may  be  discovered  till  after  the  appearance  of  ab- 
scess, or  signs  of  general  or  local  weakness  and  pain.  Adults  usually  re- 
mark pain  and  weakness  before  deformity.  The  erector  spinae,  rigid  at  first, 
soon  atrophies.  Deformity  varies  in  extent  from  the  slightest  degree  up  to 
a  huge  "  hump."  Compensatory  curves  in  the  lumbar  and  cervical  regions 
make  the  chin  project  and  the  head  sink  down  beneath  the  shoulders.  To 
take  weight  off  spine,  patient  supports  himself  with  his  hands  on  his  knees. 
When  picking  up  an  article  from  the  floor,  he  squats  down,  keeping  the 
affected  part  of  his  back  rigid.  If  the  atlo-axial  joint  be  affected,  he  turns 
his  body  to  the  right  or  left  instead  of  rotating  his  head.  Pain  may  be 
absent.  In  acute  cases  pain  and  tenderness  are  excessive.  Often  more 
pain  is  felt  in  the  side  or  abdomen  than  in  the  spine.  Paraj)legia  may 
come  on,  or  temporary  want  of  control  over  the  sphincters.  Incapacity  for 
and  dislike  to  active  exercise :  health  suffers  in  consequence.  When  ab- 
scess opens  and  chronic  septicaemia  results,  health  may  break  down  rapidly, 
or  abscess  may  dwindle  to  a  comj)aratively  unimportant  sinus.  Diagnosis. 
— Usually  easy.  Difficult  (1)  at  commencement,  (2)  when  it  occurs  in  hys- 
terical females.  A  lateral  cuiwature  often  results  from  caries  of  the  lum- 
bar vertebrae  ;  but,  in  this  case,  there  is  no  rotation,  as  in  true  lateral  curva- 
ture, and  there  are  probably  collateral  signs  of  caries,  e.g.,  abscess.  Some 
persons  attach  importance  to  eliciting  pain  by  concussing  the  top  of  the 
head,  or  by  running  a  hot  sponge  down  spine.  Stiffness  of  sj^ine  an  early 
sign.  Prognosis. — Favorable  as  regards  life  when  proper  treatment  is 
adopted.  Prospect  of  undoing  angle  of  curvature  hopeless.  Paraplegia 
is  frequently  recovered  from.  Treatment. — Three  classes — (1)  rest  in  bed, 
(2)  movable  supports,  (3)  fixed  supports.  Also  general  treatment.  Kest 
in  bed  essential  in  the  worst  cases,  e.g.,  those  complicated  by  paraplegia 
and  abscess  ;  but  it  is  itself  injurious,  by  taking  away  the  benefits  of  fresh 
air  and  exercise,  and  even  when  in  bed  the  spine  should  be  securely  fixed. 
Spinal  supports  are  of  various  kinds.  If  an  apparatus  be  applied,  it  should 
be  frequently  examined  and  adjusted.  Fixed  apparatus,  plaster-of-Paris, 
poro-plastic,  death er,  paraffin,  etc.  To  Sayre  is  chiefly  due  credit  of  demon- 
strating their  value.  He  uses  bandages  with  plaster-of-Paris,  applying 
them  fi'om  below  the  anterior  superior  iliac  spines  up  to  the  armpits, 
while  the  patient  is  suspended  by  a  collar  beneath  the  chin  and  loops  in 
the  axillae,  his  toes  only  touching  the  ground.  The  bandages  are  made  of 
crinoline.  Pads  of  cotton-wool  over  epigastrium,  female  breasts,  and 
prominent  spines.  Tight-fitting  jersey  next  skin.  Patient  lies  horizontally 
for  an  hour  after  application  of  jacket  (longer  if  convenient).     Similar  ap- 


SPINE,    DISEASES    OF.  213 

paratus  applied  witli  patient  in  supine  position  (Walker),'  or  suspended 
from  the  armpits  and  hips  in  prone  position  (Willett),  or  in  hammock 
(Davy).*  Patient's  complaints  as  to  pain,  etc.,  should  be  attended  to,  lest 
a  sore  form  from  pressui*e  over  projecting  spines.  The  suspending  ro^je 
should  be  held  by  hand,  as  grown-up  people  sometimes  faint,  and  require 
instantly  lowering  to  the  horizontal,  and  little  children  might  get  hanged 
if  hooked  up  and  left.  Case  should  be  cut  up  at  least  once  in  three  or  four 
months  ;  six  months  minimum  of  treatment.  With  a  Sayre's  case,  exercise 
and  play  become  enjoyable  in  cases  where  walking  had  previously  been  im- 
possible. In  case  of  pain  near  the  jirominent  spine,  cut  a  trap-door  in  the 
case.  When  the  cervical  region  is  affected,  the  head  should  either  be  sus- 
pended from  a  jury-mast,  or  supported  by  a  leather  collar,  well  moulded  to 
the  chin,  occiput,  and  base  of  the  neck.  Use  the  jury-mast  also  in  upper 
dorsal  cases.  Constitutional  treatment  is  conducted  on  general  principles. 
Cod-liver  oil,  Parrish's  food,  sea-side,  fresh  air,  sufficient  diet,  repose,  etc. 
Abscess. — Its  opening  should  be  delayed  as  long  as  possible ;  and  then 
strict  antiseptic  treatment  should  be  carried  out. 

Spine,  Lateral  Cukvatuke  of. — In  practice  the  lateral  curvatvires  which 
sometimes  result  from  empyema  or  from  lumbar  caries  are  not  included 
under  this  head.  Causes. — Muscular  weakness  and  excessive  sitting  or 
standing  in  a  lounging  position  about  the  age  of  puberty.  Female  sex 
much  more  than  male.  Inequahty  in  length  of  lower  extremities.  Rickets. 
Rachitis  adolescentium.  {See  Knock-knee.)  Pathology . — Always  a  jirimary 
and  secondary,  sometimes  a  third  and  fourth  curve.  Lumbar  curve  has 
its  convexity  to  the  left  nine  times  out  of  ten.  Lumbar  and  dorsal  curves 
together  form  a  line  like  the  italic  S.  Simultaneous  rotation  of  vertebr;x?, 
so  that  in  each  curve  the  bodies  of  the  vertebrae  which  form  it  are  tui-ned 
toward  its  convexity.  Hence  the  actual  extent  of  lateral  curvature  of  the 
bodies  is  greater  than  the  apparent  amount  of  curvature  noticeable  by 
merely  examining  the  spines.  Hence,  also,  the  transverse  processes  on  the 
side  toward  the  convexity  are  twisted  backward,  while  those  on  the  side 
of  the  concavity  turn  forward.  Thorax  is  rotated  forward  and  com- 
pressed on  the  concave  side,  and  rotated  backward  and  dilated  on  the 
convex  side  of  the  dorsal  cuiwe.  Waist  sinks  in  on  concave  side  of  lum- 
bar curve  and  disappears  on  the  opposite  side,  where  its  place  is  taken  by 
a  depression  half-way  up  the  thorax.  Thus  in  an  ordinary  case  of  lateral 
curvatui'e  we  should  notice,  (1)  in  the  middle  line,  the  row  of  spinous  pro- 
cesses curved  with  the  lumbar  convexity  to  the  left  and  the  dorsal  to  the 
right ;  transverse  processes  prominent  on  the  convexities,  sunk  in  on  the 
concavities  ;  (2)  on  the  left  side,  the  waist  bulging,  a  spurious  waist  caused 
by  a  depression  in  the  thorax,  and  the  thorax  itself  prominent  anteriorly, 

'  See  British  Medical  Journal,  December,  1878. 

*  See  St.  Bartholomew's  Hospital  Reports,  vol.  xiv. 


214  SPINE,    DISEASES    OF. 

flattened  posteriorly,  and  compressed  tlirougbout ;  (3)  on  the  right  side 
the  shoulder  prominent  ("growing  out"),  the  thorax  dilated  and  forming 
a  large  swelling  posteriori}',  the  waist  svmk  in,  and  the  hip  prominent.  In 
bad  cases  the  last  rib  on  this  side  impinges  on  the  ihac  crest.  It  is  ex- 
tremely hkely  that  the  immediate  cause  of  lateral  curvature  is  a  softened 
state  of  the  bones  due  to  an  affection  of  the  epijDhyseal  cartilages,  like  that 
which  causes  knock-knee.  The  ciu'vatures  become  confirmed  by  the  bones 
themselves  altering  in  shape,  atrophying  where  the  pressure  is  increased, 
hypertropliying  where  the  pressure  is  taken  off.  Signs  are  essentially  the 
naked-eye  appearances  which  result  from  the  changes  just  described. 
Diagnosis. — See  Angular  Curvature.  To  distinguish  structural  from  tem- 
porary lateral  curvature,  make  the  patient  bow  down  low.  In  the  former 
case  the  curve  in  the  back  persists.  Prognosis. — Difficulty  of  cure  very 
great.  Severe  cases  of  any  dvu'ation  very  nearly  hopeless.  Even  commenc- 
ing cases  require  most  vigilant  management.  Treatment. — Various  plana. 
Almost  all  endeavor  to  combine  extension,  exercise,  and  localized  pressure. 
Many  forms  of  spinal  support.  Sayre's  j)laster  case.  Gymnastic  exercises, 
especially  swinging  by  the  hands.  Standing  and  sitting  are  to  be  avoided. 
Eest  should  be  taken  in  the  horizontal  position.  Attend  to  general  health. 
Tonics  ;  fresh  air.  Treat  menstinial  irregularities.  Of  course,  search 
should  be  made  after  any  possible  exciting  cause,  and  its  removal  eifected 
if  j)ossible.  Friction  to  restore  tone  to  spinal  muscles.  According  to  my 
exjJeiience,  Sayre's  treatment  at  least  prevents  bad  cui-vatures  from  getting 
worse,  greatly  improves  moderate  ones,  and  even  cures  incipient  cases  ; 
but  daily  extension  by  coUar  and  pulleys  is  essentiaL ' 

Spixe,  Axtero-Posterior  Curvatures. — Lordosis,  Kyphosis.  Sometimes 
arise  from  causes  precisely  analogous  to  those  of  lateral  curvatui*e.  Fre- 
quently secondary  to  hip  disease.  In  lordosis  the  concavity  is  posterior, 
in  kyphosis  it  is  anterior.  Treatment. — Drilling,  careful  exercise,  with  in- 
tervals of  abundant  horizontal  repose.  Attention  to  posture.  Treat  rickets 
if  present.  In  these  cases,  Sayre's  plaster  corset  combined  with  daily  ex- 
tension should  be  employed  for  a  considerable  time,  then  left  off  gradually, 
the  intervals  of  wearing  it  being  occupied  in  judicious  exercises,  frictions, 
careful  attention  to  can-iage,  and  abundance  of  horizontal  rest. 

Spine,  Hysterical. — Sometimes  simulates  spinal  caries  in  young  women. 
Spasms,  paralysis,  difficult  micturition,  local  tenderness.  But  "  tenderness 
is  excessive  and  superficial,  so  that  the  patient  flinches,  and  complains 
more  when  the  skin  is  pinched  than  when  the  vertebrae  are  pressed.'"'' 
There  is  never  found  the  stiffness  characteristic  of  spinal  caries.  No  pro- 
portionate general  wasting.  Probably  weak  circulation  and  uterine  or 
ovarian  disorder.     Treatment. — See  Hysteria. 

'  I  speak  confidently  on  this  subject,  for  I  have  now  taken  a  part  in  the  application 
of  nearly  seven  hundred  plaster  Jackets. 

^  See  Savory,  in  Holmes's  System,  vol.  i.,  p.  381. 


SPINE,    INJURIES    OF.  *  215 

Spina  Bifida. — Causes. — Defective  development  and  non-union  of  verte- 
bral laminae  and  spines,  usually  in  lumbal*  region.  Excess  of  cerebro-spinal 
fluid  in  fetal  life,  according  to  Lowne.  Pathology. — Perhaps  primaz'ily  a 
local  inflammatory  dropsy  of  spinal  meninges.  At  all  events,  these  mem- 
branes bulge  through  defect  in  spinal  canal.  Spinal  cord  or  spinal  nerves 
often  in  the  tumor  (when  present,  always  in  middle  line,  though  often  widely 
spread).  Dura  mater  and  arachnoid  blend  with  skin.  Symptoms. — A  fluc- 
tuating tumor  in  median  line  behind,  usually  in  lumbar  region,  sessile  or  pe- 
dunculated, often  translucent,  spriuging  from  the  bones  ;  may  be  partially 
reducible  by  pressure — such  pressure  may  cause  spasms  or  convulsions. 
May  swell  when  child  cries.  Skin  thickened  and  rough  or  thin  and  bluish 
red.  Diagnosis. — It  is  usually  easy  to  see  that  a  true  spina  bifida  is  one. 
It  is  not  always  easy  to  be  certain  that  a  cyst  closely  connected  with  the 
bones  is  not  one.  Compare  each  case  with  the  signs  just  detailed.  Prog- 
nosis.— Grave.  More  hopeful  when  the  neck  of  tumor  is  very  naxTOW, 
Treatment. — (1)  Palliative,  (2)  radical.  Palliative  :  a  leaden  shield,  well 
padded  and  accurately  fitting.  Radical :  three  forms,  viz.,  (1)  injection 
with  iodine,  (2)  pressui'e,  (3)  excision.  Operation  very  dangerous  ;  and 
surgeon  should  be  content  with  palliative  measures,  unless  tumor,  is  getting 
steadily  worse  or  on  point  of  bursting.  Pedunculated  tumors  offer  best 
prospect  of  success  fi'om  injection.  An  endeavor  should  be  made  to  isolate 
sac  from  general  cavity  of  spinal  membranes  during  injection.  Sometimes 
long-continued  pressure,  e.g.,  by  Dupuytren's  enterotome,  will  effect  this 
isolation  permanently,  and  thus  cure  the  case.  To  inject  iodine,  a  part  of 
the  fluid  should  first  be  drawn  off,  and  then  two  drops  of  pure  tinctitre  of 
iodine  injected  {see  Holmes's  "System,"  vol.  v.,  p.  806).  Repeated  as- 
piration may  be  tried  without  injection.  Morton  of  Glasgow  has  been 
very  successful  with  the  following  injection  :  iodi.,  gr.  x.;  pot.  iod.,  gr.  xxx.; 
glycerini,  3  j.  About  3  ss.  to  3  ij.  is  injected  through  a  medium-sized 
cannula.     Repeat  if  necessary.     Avoid  imnecessary  escape  of  spinal  fluid. 

Spine,  Injuries  of,  include  dislocation,  fracture,  and  sprain.  With 
these  should  be  studied  concussion,  traumatic  compression,  and  traumatic 
inflammation  of  the  spinal  cord  and  its  membranes. 

Spine,  Dislocations  of. — Causes. — Usually  indirect  violence,  e.g.,  the 
back  being  violently  bent  forward  by  a  soft  body  falling  on  the  head  of  a 
person  stooping.  Occasionally  direct  violence,  or  even  (in  atlo-axial  region) 
destruction  of  the  Hgaments  by  disease.  Usual  Situation. —luower  cervical 
region.  Direction. — Upper  vertebra  is  almost  always  displaced  forward. 
Signs. — Mostly  "  rational "  and  indirect.  The  most  important  depend  on 
injury  to  the  cord :  paralysis  of  parts  supplied  by  nerves  given  off  below 
seat  of  injury.  Perhaps  local  pain  and  tenderness.  Shock:  collapse  at 
first.  In  some  cases  manifest  deformity.  .  Variations  in  Symptoms  accord- 
ing to  Seat  of  Injury. — (1)  Dislocation  in  lower  lumbar  region.  As  a  rule, 
merely  partial  paralysis  of  lower  limbs  or  pelvic  organs  fi-om  partial  in- 


216  SPINE,    INJURIES    OF. 

juries  to  cauda  equina  ;  (2)  upper  lumbar  region — paralysis  of  lower  limbs 
and  sphincters  ;  (3)  lower  dorsal — paralysis  of  abdominal  wall  also ;  (4) 
upper  dorsal — impaired  breathing  from  paralysis  of  intercostals  ;  (5)  lower 
cervical — paralysis  of  every  part  below  neck  except  diaphragm,  respiration 
entirely  diaphragmatic  ;  (6)  above  third  cei'vical  vertebra,  i.e.,  above  origin 
of  phrenic  nerve — instant  death.  Of  course  the  higher  lesions  include  all 
the  paralytic  effects  of  the  lower.  Priapism.  Later  symptoms  :  alkalinity 
of  urine  and  catarrh  of  urinary  organs ;  bed-sores.  These  last-mentioned 
complications  cause  death  eventually.  But,  in  cervical  dislocations,  death 
results  from  obstruction  of  the  lungs  by  frothy  secretion.  Diagnosis. — 
From  (1)  fracture,  hardly  possible.  From  (2)  mere  concussion,  by  sudden 
onset  and  by  nature  of  cause  ;  also  by  deformity  when  there  is  any.  Frog- 
nusis. — Its  badness  varies  directly  with  the  height  of  the  vertebra  displaced. 
High  cervical  dislocations  perish  usually  in  from  two  to  three  days,  dorsal 
in  two  or  three  weeks.  But  dorsal  may  recover,  lower  dorsal  frequently. 
Lumbar  offer  hopes  even  of  complete  cure.  Treatment. — Best  on  back. 
Gentle  examination  and  nursing.  Gentle  extension.  Withdraw  ui-ine 
twice  daily ;  wash  out  bladder  if  urine  become  alkaline  (see  Bladdee, 
Cat.vrrh  of).  Attend  to  bowels  with  enemas.  The  nursing  is  of  vital  im- 
portance. Smooth,  clean  sheets,  gentle  change  of  position,  dryness,  daily 
examination  of  sacral  and  trochanteric  prominences.  Good  food.  Trephin- 
ing is  for  the  most  part  condemned.  In  certain  cases  of  injury  to  the  spine, 
especially  if  in  lumbar  region,  it  would  be  justifiable  to  apply  a  plaster-of- 
Paris  corset  during  extension.     SajTe  has  published  a  case  of  this  sort. 

Spine,  Fracture  of. — Almost  everything  written  above  of  dislocations 
is  applicable  to  fractures.  In  practice  it  is  very  seldom  that  any  distinc- 
tion is  or  can  be  made  during  patient's  life.  Seat. — More  frequent  in  the 
cervical  region,  but  common  enough  in  the  dorsal. 

Concussion  of  the  Spine. — A  term  appHed  to  a  variety  of  traumatic 
affections  which  can  easily  be  differentiated  post  mortem,  and  sometimes 
more  or  less  easily  diagnosed  duiing  life.  They  concur  in  having  one 
common  cause,  and  in  tending,  so  far  as  the  worst  cases  of  each  kind  go, 
toward  similar,  if  not  identical,  terminations.  The  common  cause  is  in- 
jury to  the  cord  without  fracture  or  dislocation  of  the  spine.  The  worst 
termination  is  disorganization  of  the  cord  with  consequent  paralysis. 
Fortunately  most  cases  stop  short  of  this.  Conditions  included  in  the 
term  "  Concussion  of  the  Spine." — 1.  Mere  concussion.  2.  Compression 
from  hemorrhage  or  effusion.  3.  Laceration.  4.  Inflammation.  Causes. 
— Injury,  direct  or  indirect,  to  the  spinal  column.  Especially  common  in 
railway  accidents.  Blows,  falls.  Pathology. — Amount  of  visible  injury  in 
the  coi'd  varies  from  slightest  swelling  or  ecchymosis  to  considerable  con- 
tusions, lacerations,  ecchymoses,  effusions,  and  hemorx'hages.  Membranes 
of  cord  suffer  also.  Ligaments  of  spinal  column  sometimes  sprained  or 
torn.     At  a  later  stage  are  found  softenings  and  thickenings,  and,  still 


SPRAINS,  217 

later,  atrophy  or  disintegration.  Signs. — The  most  serious  symptoms 
arise  much  more  from  secondary  inflammation  than  from  the  injuiy  itself. 
Concussion  may  be  localized  or  diffused.  When  the  injury  is  localized  to 
one  part  of  the  cord,  either  (1)  the  rational  symptoms  are  confined  chiefly 
to  paralysis  or  irritation  of  the  nerves  ai-ising  from  that  part,  or  (2)  the 
local  mischief  is  severe  enough  to  damage  the  functions  of  all  the  cord  be- 
low seat  of  injury.  But  the  smallest  local  injury  may  serve  as  the  starting- 
point  for  the  gravest  general  disease.  In  diffused  or  general  concussion 
the  signs  are  often  remarkably  vague  and  insidious.  Earliest  are  lassitude, 
irritability,  "inaptitude,"  sleeplessness.  Then  come  pains  and  numbness 
in  various  parts.  Next,  fixed  pain  in  the  back  and  rigidity  of  the  spine 
announce  definitely  the  presence  of  spinous  or  intra-spinous  inflammation. 
Then  uncertain  gait,  general  clumsiness,  disorders  of  sight,  hearing,  taste, 
or  smell,  mental  confusion,  paralysis.  Diagnosis. — (1)  From  fracture  or 
dislocation  of  spine  {see  Dislocation  op  Spine)  .  The  symptoms  are  usually 
less  decided,  less  sudden,  and  less  severe.  (2)  From  malingering.  Some- 
times very  difficult.  Attach  greatest  weight  to  objective  symptoms,  but 
notice  if  any  of  these  vary  when  patient  is  off  his  guax-d.  Cross-examine 
about  subjective  symptoms ;  but  gross  exaggeration  is  not  uncommon  even 
when  real  concussion  is  present,  so  the  detection  of  one  falsehood  proves 
little.  Test  by  galvanism.  Muscles  really  paralyzed  do  not  contract 
properly  under  galvanism.  Extensor  muscles  usually  most  affected.  Prog- 
nosis.— When  symptoms  last  long  and  are  extensive,  recovery  is  very  un- 
likely. Treatment. — The  most  trivial  case  deserves  complete  rest  in  hori- 
zontal posture  till  the  symptoms  have  entirely  passed  away.  Prone 
position  preferable.  Moderate  or  low  diet.  No  stimulants.  Calomel,  gr. 
v.-x.  When  local  pain  or  tenderness  is  present,  dry  cupping.  Ice-bags. 
Pot.  bromid.  and  chloral  hydrat.,  gr.  xx.-xxx.,  at  night.  Later  stages : 
Mercury,  e.g.,  liq.  hydrarg.  perchlor.,  3  j.  t.  d.  s.;  or  pot.  iod.  Counter- 
irritation  over  spine,  blisters,  etc.  Still  later,  when  active  disease  in  the 
spine  seems  to  have  passed  away  while  its  effects  remain,  employ  strychnia, 
tonics,  exercise — passive  or  active — shampooing,  galvanism.' 

Spinal  Cokd,  Traumatic  Inflammation  of,  and  Spinai^  Coed,  Compression 
OF,  are  noticed  as  secondary  phenomena  occiu'ring  in  the  course  of  a  case 
of  Concussion  of  the  Spine  {see  above). 

Sprains. — A  class  of  injuries  in  which  the  soft  parts  of  and  about 
joints  are  stretched  or  torn.      Causes. — Usually  a  sudden  wrench  or  twist 

'  I  would  venture  to  suggest  that  in  the  case  of  many  patients,  especially  those 
with  trivial  concussion,  who  will  not  keep  the  prone  position,  e.g.,  fractious  children, 
and  in  the  case  of  other  patients  convalescing,  a  plaster-of- Paris  jacket  would  be  use- 
ful. Certainly  nothing  does  so  much  good  to  the  very  common  injuries  of  the  joints 
of  the  limbs  to  which  children  are  subject ;  and  many  cases  of  so-called  "spinal  con- 
cussion" must  be  primarily  sprains  of  inter- vertebral  ligaments,  while  other  cases 
would  benefit  from  thorough  local  rest 


218  SPRAINS. 

occurring  wlien  the  patient  is  unprepared  to  bring  bis  muscular  power  to 
tbe  assistance  of  bis  ligaments.  Sprains  not  imfrequently  accompanied 
by  fracture,  tbe  tendons  or  ligaments  in  sucb  cases  being  stronger  tban 
tbe  bony  processes  to  wbicb  tbey  are  attached.  Complete  rupture  of  a 
tendon  is  commonly  described  as  an  accident  distinct  from  a  sprain  {see 
Tendons,  Injukies  of).  Most  sprains  of  severity  involve  laceration  of  the 
capsular  Hgament.  Blood  is  rarely  effused  into  tbe  joint  in  any  quantity, 
but  subcutaneous  ecchymosis  is  very  common.  Serous  effusion  into  joint- 
cavity,  and  inflammatory  swelling  of  surrounding  soft  parts,  take  place. 
Pain,  often  excruciating,  beat,  and  tenderness — usually  best  marked  at  cer- 
tain points.  Diagnosis  is  to  be  made  from  fracture  by  negative  evidence. 
Trust  as  much  as  you  safely  can  to  your  eye,  and  to  tbe  history  of  the 
case.  Prolonged  physical  search  for  crepitus  to  be  much  condemned. 
Treatment. — Methods  apparently  diametrically  opposed  succeed  with  these 
injuries.  In  tbe  great  majority  of  cases  nature  is  thoroughly  competent  to 
cure  sprains  unassisted.  Many  people  "walk  them  off,"  as  they  say. 
Sprained  thumbs  habitually  get  what  is  really  no  treatment  at  all ;  yet, 
common  and  severe  as  they  are,  how  rarely  any  permanent  harm  comes 
from  them !  On  the  other  hand,  almost  all  the  surgical  authorities, 
alarmed  by  the  number  of  joint  diseases  and  the  like  which  are  attributed 
(truly,  no  doubt)  to  neglected  sprains,  warn  us  to  fix  sprains  with  wooden 
or  iron  splints  for  weeks.  There  may  be  some  doubt  about  the  amount  of 
liarm  to  be  really  attributed  to  treating  sprains  by  motion  ;  but  there  can 
be  no  question  whatever  about  the  mischief  done  by  the  abuse  of  rest. 
Bone-setters  depend  for  their  Hving  upon  the  orthodox  and  blind  worship 
of  splints.  A  treatment  which  will  be  found  very  successful  (see  the  writ- 
ings of  Hood,  Cowling,  Pilcher,  and  the  traditional  practices  of  thousands 
of  the  laity)  is  to  supply  the  place  of  the  torn  Hgaments  by  applying  care- 
fully and  thoughtfully  bandages  outside  the  joint,  to  limit  effusion  and  in- 
flammation by  the  pressure  of  such  bandages,  and  to  secure  elasticity, 
and  thus  permit  a  certain  amount  of  movement,  by  means  of  plenty  of  good 
cotton-wool,  or  else  by  using  india-rubber  bandage,  which  probably  fulfils 
all  the  above  indications  better.  This  india-rubber  bandage,  if  properly  ap- 
plied, gives  great  relief  in  cases  of  flat-foot,  tbe  pain  of  which  arises  partly 
from  a  kind  of  chronic  spraining  of  ligaments  and  tendons.  When  the 
sprain  is  severe,  complete  rest  for  a  few  days  may  be  desirable,  and  se- 
vere exercise  should  certainly  never  be  allowed  tni  it  is  quite  well.  The 
mobile  treatment  prescribes,  or  rather  permits,  only  gentle,  regulated, 
hmited  movements ;  and  what  it  chiefly  condemns  is  the  continual  and  re- 
peated resort  to  spHnts.'     Under  such  a  treatment  it  sometimes  happens 

'Billroth.  Sir  James  Paget  says:  "In  deciding  upon  resorting  to  manipulation 
in  old  cases,  I  believe  you  will  be  safe  if  you  will  take  the  temperature  of  the  part 
for  your  guidimce."     Rest  is  counterindicated  when  the  joint  is  cold. 


SYPHILIS.  2 1  0 

that  each  fresh  walking  experiment  reveals  a  worse  and  worse  state  of 
things  ;  the  patient  goes  to  the  bone-setter,  submits  to  a  httle  violence, 
courageously  defies  his  doctor's  warnings,  walks  about,  and  gets  well. 
When  the  treatment  above  sketched  fails,  as  it  will  sometimes,  then  is  the 
time  for  putting  on  a  plaster-of-Paris  case.  The  perfect  recovery  of  old 
sprains  is  often  prevented  by  the  presence  of  adhesions  in  or  about  the 
joint.  Break  down  these  by  free  movements.  If  inflammatory  reaction  is 
feared,  fix  up  the  limb  for  a  few  days  and  apply  an  ice-bag. 

Sterility. — In  males,  usually  a  consequence  of  impotence,  quod  vide. 
But  there  are  probably  cases  in  which  men  perfectly  virile  are  yet  sterile. 
No  rules  can  be  given  for  the  treatment ;  but  if  the  surgeon  should  be 
consulted  on  such  a  case,  he  should  inquire  carefully  into  it,  and  possibly 
he  may  do  good — even  if  it  be  only  by  finding  that  the  patient  is  not  really 
sterile  at  all. 

Sternum. — Liable  to  necrosis  from  syphilis,  from  struma,  or  from  in- 
jury. This  may  lead  to  abscess  and  perforation,  and  occasionally  to 
mediastinal  abscess.  Treatment. — Apply  general  principles,  for  which  see 
Bone,  Necrosis  of,  and  Stphelis,  etc. 

Synovitis. — See  Joints. 

Syphilis.— Former  extended  application  of  the  term  so  as  to  include 
all  venereal  diseases,  even  gonorrhoea.  In  modern  language  usually  re- 
stricted to  the  constitutional  disease,  and  to  such  primary  sores  as  are  fol- 
lowed by  infection  of  the  system.  But  it  is  considered  natural  and  con- 
venient by  most  writers  to  place  together,  for  descriptive  purposes,  the 
soft  non-infecting  chancre  and  the  "hard"  or  "Hunterian"  chancre  with 
its  consequences.     The  same  plan  will  be  followed  here. 

Venereal  Diseases. — 1,  Gonorrhoea  {see  separate  notice) ;  2,  soft  sore 
(false  syphilis)  ;  3,  syphilis  proper. 

Soft  Sore,  soft  chancre,  simple  chancre,  chancroid.  Causes. — Inocula- 
tion from  another  soft  chancre.  According  to  Hutchinson's  views,  it  is 
non-specific  in  origin,  and  arises  merely  from  inoculation  with  pus,  the 
result  of  ordinary  suppuration  at  a  certain  stage.  Contracted  not  only 
through  impure  sexual  intercourse,  but  occasionally  also  by  accoucheurs, 
mid  wives,  etc.,  accidentally.  Bassereau,  "by  the  aid  of  repeated  confront- 
ation of  the  patients  infected  with  those  who  had  given  them  the  disease, 
succeeded  in  proving  that"  soft  chancre  "resulted  from  a  chancre  of  the 
same  kind."  Relative  Frequencxj  (as  compared  with  hard  chancre). — Four 
to  one  (8,045  to  1,955).  Objective  Characters  (period  of  incubation,  nil). — 
Successively,  redness,  slight  swelling,  vesicular  pustule,  ecthymatoid  pus- 
tule, ulcer.  Ulcer  is  rounded,  clean-punched,  spreading,  rather  deep,  with 
a  floor,  uneven,  dirty-looking,  purulent,  and  with  abundant  highly  conta- 
gious secretion.  Any  hardness  of  base  is  rare  ;  but  such  as  there  is,  is 
that  of  ordinary  inflammatory  thickening.  Course  is  progressive,  tendency 
destructive  for  three  or  four  weeks  ;  then  natural  termination  is  in  cicatri- 


220  SYPHILIS. 

zation,  with  depressed  white  soft  scar.  Complications. — 1,  Inflammation  ; 
2,  gangrene  ;  3,  phagedsena  ;  4,  phimosis.  In  consequence  of  the  habihty 
to  these,  a  classification  has  been  made  of  soft  chancres  into  1,  simple  ;  2, 
phagedsenic  ;  3,  gangrenous  or  sloughing.  The  phagedsenic  is  character- 
ized by  unusually  rapid,  obstinate,  destructive  ulceration.  Its  form  is 
u-regular,  edges  hvid,  surrounded  by  copper-colored  areola ;  secretion  thin, 
very  offensive.  Occurs  in  broken-down  subjects.  Gangrenous  chancre  is 
usually  a  consequence  of  phimosis  with  inflammation.  The  prepuce  is 
the  part  which  usually  sloughs.  Great  hemorrhage  may  occur.  Usual 
Posilions  of  Chancre  in  Women. — Just  inside  fourchette  or  labia  minora. 
Sometimes  on  cervix  or  os  uteri.  Diagnosis. — From  herpes,  by  the  latter 
being,  at  most,  an  excoriation.  From  Hunterian  chancre,  by  absence  of 
characteristic  induration,  by  state  of  inguinal  glands,  by  more  active  char- 
acter of  ulceration,  and  by  ulcers  appearing  immediately  after  exposui'e  to 
contagion.  Prognosis. — Soft  chancre  has  been  said  to  occasionally  lead  to 
constitutional  syphihs.  The  advocates  of  dualism  {i.e.,  the  gi-eat  mass  of 
modern  authority)  deny  it.  Bubo  (suppurating)  attends  or  follows  soft 
chancre  occasionally,  especially  if  chancre  affect  fraenulum,  or  be  imtated. 
Treatment. —  1.  Of  simple  chancre:  Restrict  walking  exercise.  Low  or 
moderate  diet,  cleanliness,  wash  with  hot  water  twice  daily,  each  time 
dressing  with  lint  and  lotio  nigra  (calomel,  3  j-;  aquoe  calcis,  3  iv.),  or  blue 
wash  (cupri  sulph.,  gr.  j.;  aqua,  |  j.),  or  with  iodoform  (contraindicated  if 
the  sore  be  inflamed).  If  seen  in  first  week  cauterize  with  any  caustic 
(argent,  nit.,  acid,  nit.,  acid,  carbol.  fort,  etc.).  In  later  stage,  when  indo- 
lent, stimtdation  with  ung.  hyd.  oxid.  rubri,  or  a  touch  of  argent,  nit.  may 
do  good.  For  painful  erection  at  night,  use  moi-phia  suppositories.  When 
phimosis  is  present,  tiy  fi-equent  hot  injections  beneath  prepuce,  rest,  and 
elevation.  Avoid  operation  if  possible.  2.  Phagedfenic  chancre  requires 
generous  diet,  regulation  of  digestive  and  other  systems,  opium  inter- 
nally, and  local  caustic  and  antiseptic  applications  (carbolic  oil,  i.-x.  Acid, 
nitric,  dil.,  3j. ;  aquse,  |  iv.).  Some  sores  can  only  bear  non-irritant 
lotions,  such  as  lead  and  opium.  Change  of  air  often  seems  to  act  won- 
derfully. 

Bubo. — See  separate  notice  in  alphabetical  order.  In  addition  to  the 
notes  given  there,  it  may  be  stated  that  the  bubo  consequent  on  a  soft 
chancre  is  itself  a  chancre  of'  the  gland  affected.  Matter  from  the  interior 
of  this  suppurating  gland  wiU,  when  inoculated,  excite  a  true  soft  chancre. 

Syphilis  {true  syphilis)  is  either  acquired  or  hereditary. 

Acquired  Syphilis. — Ordinary  true  syphilis.  Causes. — Always  conta- 
gion ;  almost  always  direct  contagion,  e.g.,  impure  sexual  intercourse, 
kissing,  nursing  {i.e.,  suckling),  unnatural  offences,  and  sometimes,  unfor- 
tunately, the  performance  of  obstetric  duties.  The  blood  and  other  con- 
stituent fluids  of  a  syphilitic  patient  are  capable  of  syphilizing  by  inocula- 
tion.    But  excretions  of  such  a  patient  are  innocuous.     It  is  even  stated, 


SYPHILIS.  221 

but  not  proved,  that  vaccine  lymph  can  only  transmit  syphilitic  poison 
when  mixed  with  blood. 

Pathology  and  Semeiology. — In  the  progress  of  syphilis  there  are  four 
periods,  viz.  :  1,  Incubation ;  2,  local  eruption  or  primary  lesion  ;  3, 
general  eruption,  or  secondary  syphiUs ;  4,  gummy  products,  or  tertiary 
syphilis.  "WeU-marked  differences  separate  each  of  these  j^eriods ;  in 
the  first  it  is  the  complete  absence  of  local  manifestations  ;  in  the  second, 
the  presence  of  a  single  unique  modification  of  the  tissues  at  the  point  of 
deposition  of  the  contagious  matter.  Numerous  but  superficial  lesions, 
which  generally  leave  no  appreciable  trace  of  their  passage,  characterize  the 
third  {i.e.,  secondary)  period  ;  while  the  fourth  is  distinguished  by  changes 
more  deep-seated,  and  usually  followed  by  cicatrices.  Moreover,  inocula- 
ble  and  hereditary  in  the  second  and  third  periods,  syphilis  does  not  ap- 
pear to  be  contagious  either  in  the  first  or  in  the  last "  (Lancereaux). 

Period  of  Incubation. — Three  to  five  weeks.* 

Local  Eruption  (Primary  Sj'philis)  ;  Hunterian  or  Hard  Chancre ;  In- 
fecting Chancre. — Microscopically  examined,  every  hard  chancre  evidently 
owes  its  hardness  to  cellular  infiltration  and  consecutive  formation  of  new 
fibrous  tissue,  and  the  ulceration  is  partly  due  to  "  granulo-fatty  metamor- 
phosis "  of  the  infiltration  and  the  infiltrated  tissue. 

Three  kinds  of  hard  chancre  :  1,  dry  papuli ;  2,  chancriform  or  chan- 
crous  erosion  ;  3,  ordinary  Hunterian  chancre. 

Dry  Papuli. — ^Very  rare.  "  A  papular  protuberance,  usually  having  the 
form  of  a  patch,  one  or  more  centimetres  in  extent,  of  a  dark  or  hrowniiih 
red  color,  round  or  oval,  firm  and  elastic,  and  sometimes  covered  with 
whitish  scales,  which  give  it  a  certain  analogy  with  the  syphilitic  papules 
of  the  next "  {i.e.,  secondary)  "  period." 

C'hancroiis  or  Chancriform  Erosion ;  Parchment-like  Chancre  of  Ricord. 
— Usually  occurs  just  behind  corona  glandis.  When  pinched  up  be- 
neath the  finger,  it  feels  like  a  thin,  hard  wafer,  or  piece  of  parchment. 
Two  such  chancres  out  of  three  leave  no  permanent  duration  behind 
thefta. 

Ordinary  Hunterian  chancre  not  only  has  a  hard  base,  but  is  surrounded 
by  an  elevated,  hard,  callous  border,  so  that  it  is  deeper  in  the  middle 
than  at  the  periphery.  When  the  result  of  inoculation,  its  successive  ap- 
pearances have  been  observed  to  be  as  follows  :  red  spot,  red  or  dirty  yel- 
low papule,  covering  of  grayish  scales,  scales  accumulated  to  a  crust,  finally 
a  cup-shaped  ulcer.  Fully  developed,  its  surface  is  indolent,  glossy,  larda- 
ceous,  and  its  secretion  scanty,  thin,  degenerate,  not  pus,  and  not  rein- 
oculable  on  the  same  subject.     Usually  heals  after  about  six  weeks.     The 

'  In  vaccino- syphilis  the  vaccine  scar  begins  to  show  Ryphilitic  signs,  e.g.,  inflam- 
mation and  induration,  about  a  month  after  inoculation,  in  the  meantime  the  pustule 
having  followed  quite  a  normal  healing  course. 


222  SYPHILIS. 

characteristic  hardness  feels  like  half  a  split  pea,  and  does  not  usually  en- 
tirely disappear  in  less  than  four  months  ;  it  may  be  permanent. 

Seat  of  hard  chancre  is,  in  females,  usually  external  genitals,  rarely 
vagina,  sometimes  uterine  neck  or  os,  sometimes  quite  other  regions  of 
the  body. 

Indolent  Bubo  ;  True  Syphilitic  Bubo. — Glands  affected  always  multi- 
ple, usually  numerous.  Surrounding  cellular  tissue  not  affected,  each 
gland  is  consequently  distinguishable.  Characters, — hardness,  smooth- 
ness, oval  or  round  shape,  enlargement  not  great.  Sometimes  one  gland 
much  larger  than  rest.  Never  suppurates  except  under  cu'cumstances  of 
special  irritation.  Appears  coincidently  with  induration  of  chancre,  and 
considerably  outlasts  it. 

Sl'bsequent  Induration  of  other  Lymphatic  Glands,  especially  in  nape 
of  neck,  axilla,  and  groin  of  opi)osite  side,  very  frequent.  This  may  last 
for  years,  and  is  valuable  to  assist  in  diagnosing  a  case  where  history  of 
syphihs  is  not  easy  to  get. 

Secon"dary  Syphilis  ;  Period  of  General  Eruption. — Often  ushered  in 
by  feverishness,  gastric  disturbance,  dizziness,  pains  in  joints,  lassitude. 
These  symptoms  have  before  now  led  to  a  false  diagnosis  of  intermittent 
fever,  typhoid,  neuralgia,  or  rheumatism.  The  parts  chiefly  affected  by 
secondary  syphilis  are — 1,  skin  ;  2,  mucous  membrane  ;  3,  glands  ;  4,  iris 
and  neighboring  parts  of  eye. 

SJcin  Syphilides ;  Syphilitic  Exanthemata. — Varieties  :  1,  erythematous 
syphilide  ;  2,  papular  syphilide  ;  3,  pustular  sj^^ihihde  ;  4,  vesicular  sy- 
phihde  ;  5,  squamous,  and,  6,  pigmentary  syphihde.  General  diagnostic 
peculiarities  of  syphilides:  1,  copper  color;  2,  pigmentary  stains  left  be- 
hind ;  3,  indistinctness  of  type  {e.g.,  in  the  same  subject  are  seen  transi- 
tional forms  between  roseola  and  psoriasis,  and  few  or  no  patches  which 
are  distinctly  either  one  or  the  other)  ;  4,  situation  {e.g.,  syphilitic  pso- 
riasis is  not  confined  to  the  knees  and  elbows,  as  is  so  often  the  case  with 
simple  psoriasis) ;  5,  shape  of  groups  of  eruption,  usually  circular  or 
crescentic ;  6,  absence  of  itching  ;  7,  unusual  thickness  of  crusts  «ind 
scabs. 

Erythematous  Syphilide  ;  Syphilitic  Roseola. — Eose- colored  spots,  or  red 
and  slightly  raised  patches.  Generally  commences  on  trunk.  Course  slow. 
In  diagnosing  fi'om  non-syphilitic  erythemas  consider  the  history  of  the 
patient  and  the  state  of  the  glands.  Prognosis. — Usually  disappears  under 
a  month's  mercurial  treatment.  Said  to  augur  rather  a  mild  attack  of 
syphilis. 

Papidar  Syphilide.— Coipi:>erj-red  papules,  chiefly  on  trunk,  but  also  on 
limbs,  forehead,  and  hairy  scalp.     Leaves  no  permanent  scar. 

Pustular  Syphilide  ;  Syphilitic  Impetigo. — Appears  at  a  later  stage  than 
the  preceding  syphilides,  but  not  so  late  as  syphilitic  rupia,  which  indeed 
is  a  tertiary  affection.     The  pustules  suppurate,  scab,  and  leave  scars.     It 


SYPHILIS.  223 

lasts  for  several  months,  and  might  at  first  be  mistaken  for  small-pox,  and, 
later  on,  for  common  acne. 

Vesicular  Syphilide. — Extremely  rare. 

Squamous  Syphilides ;  Syphilitic  Psoriasis. — Spots  rarely  large,  color 
coppery,  scales  thin.  Fissvu-es.  Frequently  palmar  and  plantar  in  situa- 
tion. Palmar  psoriasis  characterized  by  "  slightly  prominent,  rounded 
spots,  of  a  coppery  color,  covered  with  hard  grayish  confluent  scales,  which 
in  some  cases  take  the  form  of  cracked  patches,  and  give  rise  to  chaps  and 
fissures,  which  are  often  painful."  Characteristic  brown  border  at  edges 
of  patches. 

Pigmentary  Syphilide. — Grayish  or  coffee-with-milk  colored  patches, 
size  of  sixpence,  chiefly  on  neck,  face,  and  abdomen. 

Alopecia. — "Primary  "  or  "consecutive."  By  "primary"  is  meant  the 
alopecia  which  occurs  independently  of  any  visible  anatomical  lesion  during 
the  secondary  period  of  syphUis.  "  Consecutive  is  the  alopecia  which 
attends  various  local  tertiary  syphilitic  affections.  Very  common  indeed, 
especially  in  women.  Not  confined  to  crown  of  head  like  senile  alopecia. 
Affects  scalp  irregularly.  When  of  long  duration,  indicates  a  severe 
syphilis. 

Nails ;  Onychia. — Usually  moist  and  ulcerative  ;  sometimes  dry,  and 
coexistent  with  psoriasis  elsewhere.  Affects  toes  more  than  fingers.  Part 
primarily  affected  is,  of  course,  the  matrix.  Pain  of  ulcerative  form  of- 
ten considerable.  Psoriasis  of  the  nail  makes  it  horny,  thickened,  and 
fissured. 

3Tucous  Membranes. — Especially  of  mouth,  throat,  nose,  larynx,  and 
rectum.  Secondary  affections  of  these  are  either  (1)  erythemas,  (2) 
superficial  ulcerations,  or  (3)  condylomata.  Type,  syphilitic  sore-throat 
(secondary).  Red  patches,  more  or  less  irregular,  on  pharynx,  soft  palate, 
and  often  at  same  time  on  mucous  membrane  of  cheeks.  These  may 
be  attended  or  followed  by  small  superficial  \ilcers,  surrounded  by  a  dark 
red  margin,  covered  with  yellowish  material,  and  tender,  readily  smarting. 
Must  not  be  confounded  with  mercurial  stomatitis  and  angina.  The  latter 
produce  swelled  gums  and  the  odor  of  salivation.  The  throat,  in  the  male 
sex,  is  the  commonest  seat  of  condylomata. 

Condylomata  ;  Mucous  Tubercles. — Chief  seats  :  Vulva,  pharynx,  palate, 
mouth",  anus,  buttocks,  glans  penis,  prepuce,  scrotum,  and  intervals  be- 
tween toes.  Structure  :  sarcomatous,  or  soft  connective  tissue.  Prognosis. — ■ 
They  indicate  a  very  mild  form  of  syphiHs. 

Secondary  Visceral  Affections. — Of  liver,  nervous  system,  etc.  (See 
medical  works.)  Secondary  affections  of  the  joints  occur  rarely,  and  may 
be  diagnosed  by  the  history.  Secondary  thickenings  of  the  muscles  and  of 
the  periosteum  are  very  uncommon. 

Iritis,  when  syphilitic,  may  be  distinguished  from  rheumatic  iritis  by 
a  consideration  of  the  following  table  (from  Lancereaux,  after  Desmarres) : 


224 


SYPHILIS. 


Syphilitic  Iritis. 
No  acute  symptoms. 
Slow  development  of  the  disease. 
Yellowish  green  discoloration  of  the  iris, 

dimness    of    the   cornea    and    aqueous 

humor. 
Perikeratic  circle  little  distinct. 
Synechias  and  pupillary  exudations. 
Punctated  keratitis  in  the  last  period. 
Condylomata  of  iris. 
Very  little  photophob 
No  watering  of  eyes. 
General  dulness  of  eyes. 


Rheumatic  Iritis. 

Always  acute  symptoms. 

Rapid  development. 

Neither  discoloration  nor  dimness. 


Circle  very  distinct 
Rarely  synechias. 
Never  punctated  keratitis. 
Never  condylomata. 
Photophobia  intense. 
Watering  of  cabs  abundant. 
Unusual  brightness  of  eyes. 


Course  and  prognosis  of  syphilitic  iritis  depend  greatly  upon  whether 
the  affection  de%'elops  early  or  late  during  the  secondary  period.  In  the 
latter  case,  adhesions  usually  form  between  iris  and  capsule  of  lens,  which 
keep  up  an  irritation  apt  to  lead  to  choroiditis,  retinitis,  and  permanent 
impairment  of  vision. 

Period  of  Guivimy  Products  ;  Tertiary  Syphilis. — In  the  preceding  para- 
gi-aphs,  "we  saw  the  morbid  localizations  of  syphilis  limited  chiefly  to  the 
skin,  to  some  of  the  mucous  membranes,  and  to  a  smaU  number  of  the 
\  organs,"  e.g.,  the  eye  ;  "from  this  time  syphilis  extends  its  manifestations 
beyond  these  limits,  and  we  find  it  ever^^where  where  a  web  of  connective 
tissue  exists,  that  is  to  say,  in  all  parts  of  the  body."  "It  is  no  longer  sim- 
ple hypertemias  with  or  without  exudation,  inflammations  slight  and  of 
short  duration,  but  profound  changes,  essentially  slow  in  their  evolution, 
and  marked  by  chronic  inflammations.  Sometimes  extensive  and  dis- 
seminated in  a  single  organ,  they  are  rather  comparable  to  the  chronic 
phlegmasifc  ;  sometimes  more  limited  and  circumscribed,  these  changes 
appear  in  the  form  of  nodules  or  tubercles,  and  it  is  then  that  the  name  of 
Gummy  Tumors  is  more  particularly  reserved  for  them."  These  two  an- 
atomico-pathological varieties,  differing  only  in  form,  have  the  same  start- 
ing-point and  the  same  structure.  Tertiary  syphilis  is  usually  separated 
by  a  distinct  interval  of  time  (sometimes  many  years)  from  secondary  syphi- 
lis. And  its  own  manifestations,  in  some  cases,  show  a  tendency  to  appear 
in  a  certain  order,  viz. :  firstly,  deep-seated  lesions  of  the  skin ;  secondly, 
afiection  of  the  subcutaneous  cellular  tissue,  muscles,  and  bones ;  thirdly, 
disease  of  the  viscera.  The  peculiarities  of  tertiary  syphilis  of  the  special 
organs  and  parts  are  described  under  the  corresponding  headings,  e.g., 
Bone,  Tongue,  Larynx,  Rectum,  Testicle,  Ulcers,  etc.  It  may  be  stated 
here  that  tertiary  syphilis  attacks  the  skin  as  rupia  and  ecthyma  ;  and  that 
the  great  cachexia  often  observed  at  this  stage  is  sometimes  due  to  diseases 
of  the  abdominal  absorbent  glands.  Structure  of  a  Gwmwa.— Primarily, 
granulation-tissue,  with  a  delicate  stroma  of  fibres  and  a  few  blood-vessels. 
After\\'ard,  partly  degenerates  into  a  granular  detritus.      Its  naked-eye 


SYPHILIS.  225 

appearance  has  been  well  compared  to  boiled  cod-fish,  but  it  sometimes 
really  resembles  a  solution  of  gum. 

Progf?iosis.— Certainly  is  affected  for  evil  by  bad  nourishment,  want  of 
cleanliness,  changeable  climate,  damj),  darkness,  veiy  early  age,  and  origin- 
ally feeble  constitution.  Some  cases  are  manifestly  bad,  others  as  plainly 
benignant  from  the  first.  Indications  may  be  drawn  fi'om  the  character  of 
the  prime  lesion.  Veiy  indurated  and,  still  more,  phagedenic  chancres 
are  of  e-^il  omen.  "  The  first  syphilide,"  according  to  Diday,  "  is  the  most 
valuable  sign  to  rely  upon."  With  a  trivial  I'oseola,  not  showing  any  ten- 
dency to  become  papular,  spontaneous  cure  is  almost  certain.  Papular, 
squamous,  pustular,  and  vesicular  syphihdes  indicate  probability  of  a 
worse  attack  of  syphilis.  "  Syphilis  once,  syphilis  ever,"  is  the  teaching  of 
an  influential  body  of  pathologists  who  have  yet  to  prove  their  thesis. 
Numberless  instances  have  been  observed  of  syphilitic  patients  who  during 
the  remainder  of  a  long  lifetime  have  enjoyed  sound  health,  and  begot 
families  of  vigorous,  apparently  untainted  childi-en. 

Treatment. — Public  prophylaxis.  Kegistration  and  periodical  inspection 
of  prostitutes.  In  some  Continental  towns,  males  who  Adsit  immoral  houses 
are  also  inspected.  Private  hygiene :  none  thorouglily  effective  except 
morality.  Cleanliness,  etc.  Cai*boHc  soap.  Oil  of  eucalyptus.  History 
of  treatment  of  syphilis  may  be  divided  into  three  main  periods  :  the  first, 
when  mercuiy  was  almost  ah.  in  all,  being  rivalled  only  by  g-uaicum,  sarsa- 
parilla,  and  other  vegetable  diaphoretics ;  the  second  j)eriod,  when  the 
stiU  powerful  school  of  anti-mercurialists  had  its  origin  in  the  expei-ience 
of  the  'British  army  sirrgeons  during  the  Peninsular  War  ;  and  the  third 
and  present  jDcriod,  in  which  nine  surgeons  out  of  ten  give  mercury  with 
discretion,  both  as  to  amount  and  time,  and  frequently  substitute  for  it 
iodide  of  potassium.  Practically  convenient  to  notice  treatment  of  primary, 
secondary,  and  tertiary  syphilis  independently. 

Primary  >S^i/p/uZis.  — Sigmund's  statistics  tend  to  prove  that  cauteriza- 
tion of  the  spot  inoculated  is  very  successful  in  averting,  if  only  it  be  ef- 
fected early  in  the  period  of  incubation  (before  any  chancre  has  a^jpeared).* 
Mercuiy  unable  to  prevent  secondaries,  but  useful  to  hasten  the  absorp- 
tion of  a  very  indurated  chancre,  which  is  slow  to  disappear.  Locally, 
cleanliness  and  lotio  nigra,  or  calomel  ointment  one  part  +  simple  oint- 
ment four  parts,  applied  three  times  a  day.  For  treatment  of  iDhagedsena, 
see  Soft  Chancee. 

Treatment  of  Secondary  Syphilis. — General  and  local. — General :  Mer- 
cury in  small  doses,  e.g.,  hydrarg.  c.  creta,  gr.  iij.,  bis  die;  calomel,  gr.  ij., 
with  opii,  gr.  ss.,  ter  die  ;  hydrargjTi  iodidi  vii-id.,  gr.  ij.,  ter  die  ;  pil.  hy- 
drargyri,  gr.  v.,  opii,  gr.  ss.,  bis  die  ;  liq.  hydrarg.  perchlor.,  3  j.,  ter  die.  Mer- 

'  Sir  James  Paget  and  Mr.  Hutchinson  are  in  favor  of  trial  of  cauterization  in 
early  stage  of  hard  chancre. 
15 


22G  TARSUS,    DISEASE    OF. 

curia  linimction,  ung.  hydrargyri,  3  ss.-  3  j.  rubbed  into  skin  of  inner  side 
of  tliiglis,  arms,  and  of  belly  alternately,  every  evening  ;  calomel  ointment, 
which  is  cleaner,  may  be  substituted.  The  peroxide  of  mercury  dissolved 
in  olive  oil  is  another  "elegant"  preparation  for  external  use.  Fumiga- 
tion.— Apparatus  required :  spirit  lamp,  common  tin  plate,  small  tin  for 
boiling  water,  tripod  to  support  tin  plate  over  spirit  lamp,  cane-  or  wood- 
bottomed  chair,  and  blanket.  Calomel,  gr.  xx.,  to  be  placed  on  plate  dry. 
Tin  of  boiUng  water  to  be  put  on  plate  beside  the  calomel ;  lamp  lighted  ; 
patient  sits  on  chair  with  blanket  round  him.  Lamp  to  be  blown  out  in 
ten  minutes,  but  patient  sits  a  quarter  of  an  hour  longer,  and  then  gets 
into  bed  without  drying  his  skin.  Kepeat  every  night  or  every  other 
night.  Iodide  of  potassium  often  given  in  secondary  syphilis.  Dose  v.- 
XV.  grains,  best  combined  with  some  alkali.  Iodide  of  potassium  and  liq. 
hydrarg.  j)erchlor.  sometimes  prescribed  in  same  mixture,  especially  in 
scrofulous  subjects.  Red  or  periodide  of  mercury  results.  Mercury  usu- 
ally given  cautiously  till  the  gums  become  slightly  touched,  and  then 
stopped.  When  giving  pot.  iod.  the  signs  of  iodism  should  be  watched 
for — to  guard  against  them,  not  to  produce  them.  They  are  catarrh  of 
the  mucous  membrane  of  the  nose,  frontal  sinuses,  eyes,  etc.,  great  ner- 
vous depression,  and  sometimes  a  rash.  Locally,  many  secondary  affec- 
tions require  no  treatment,  e.g.,  roseola  and  most  squamous  syphilides. 
For  sore  throat,  gargarisma  nigra  ;  for  mucous  tubercles,  calomel  +  zinci 
oxidi  aa  sequales  partes,  occasionally  argent,  nit ;  for  ulcers,  img.  hydrarg. 
oxid.  rubri,  or  calomel  ointment,  or  lotio  nigTa,  or  piirely  non-specific 
treatment.  For  intra-anal  and  rectal  affections,  cleanliness  and  mercurial 
suppositories. 

VAccmo-SYPmus  and  Hereditary  Stphtlis. — See  Appendix. 

Talipes. — See  Club-foot. 

'Tarsus,  Disease  of,  usually  begins  in  the  bones. — Diagnosis. — From 
disease  of  the  ankle-joint  by  the  swelling  being  below  the  malleoli  in  affec- 
tion of  the  astragalo-calcaneal  joint,  and  by  the  motion  of  the  ankle-joint 
being  comparatively  free ;  of  course  disease  of  anterior  part  of  tarsus  is 
easy  to  distinguish  from  ankle-joint  disease.  Diagnosis  of  exact  tarsal 
joints  and  bones  affected  very  imiDortant  from  its  bearing  on  treatment. 
When  the  swelling,  tenderness,  etc.,  are  on  the  outer  side  of  the  foot, 
whether  affecting  os  calcis  or  cuboid,  or  both,  if  disease  be  inveterate, 
excision  is  decidedly  indicated.  But  when  disease  affects  scaphoido-cunei- 
form  joints,  and  centre  of  tarsus,  the  necessity  of  amputation  is  to  be 
feared.  Excise  for  disease  of  astragalus,  or  astragalo-calcaneal  joint.  Dis- 
ease of  OS  calcis  usually  confined  to  bone,  not  reaching  any  joint  for  some 
time.  It  should  be  gouged  out.  Exact  diagnosis  is  easiest  when  there 
are  sinuses  through  which  dead  bone  can  be  felt.  Sulphuric  acid,  slightly 
dilute  (1  in  3),  well  adapted  for  dissolving  dead  bone  in  some  of  these 
cases.     Li  early  stages,  rest,  pressure,  etc.,  combined  with  out-door  exer- 


TESTICLE.  227 

cise,  indicated.  A  liigh  heel  should  be  placed  on  the  sound  foot,  a  plaster- 
df-Paris  bandage  on  the  diseased  one,  and  the  patient  sent  about  on 
crutches.     ( Vide  Bone,  Scrofula,  etc.) 

Tendons,  Ruptured,  should  be  treated  like  ruptured  muscles.  Rest 
in  relaxed  position  for  a  fortnight.  Afterward  carefrd  and  gradual  mo- 
tion for  weeks  before  attempting  free  use. 

Tendons,  Cut,  can  often  be  advantageously  united  by  suture. 

Tendons,  Syphiutio  Gummata  of,  occur. 

Testicle. — Abscess  ;  Absence  ;  Atrophy  ;  Cancer  ;  Cystic  Disease  ;  De- 
velopment Imperfect ;  Enchondroma  ;  Fibrous  and  Fibro-cystic  Tumor  ; 
Hernia  Testis  ;  Inflammation  (Orchitis  and  Epididymitis) ;  Injuries  ;  Mal- 
position—Inversion, Testicle  in  Perina^um,  Testicle  in  Groin  below  Pou- 
part's  Ligament,  Retained  Testicle  ia  Abdomen,  in  Inguinal  Canal ;  Neural- 
gia ;  Scrofulous  Testicle  ;  Sj'phUitic  Testicle. 

Testicle,  Abscess  of.  —  Causes. — Generally  chronic  or  subacute  orchitis 
of  syphilitic  or  scrofulous  origin.  Occasional  Results. — Hernia  testis,  trou- 
blesome sinuses,  and  recurrent  inflammations.  Treatment. — Apply  general 
principles.     Do  not  open  too  early. 

Testicle,  Absence  of. — An  extremely  rare  condition,  except  in  cases  of 
general  abnormality  of  the  genital  organs.  Curling  quotes  trustworthy 
case  from  the  practice  of  Page,  of  Carhsle. 

Testicle,  Atrophy  of. — Causes. — 1,  the  contraction  of  lymph  effused  in 
the  course  of  any  variety  of  orchitis ;  2,  similar  contraction  the  result  of 
hsematocele,  and  even  of  hydrocele ;  3,  excesses,  sexual  or  alcoholic  ;  4, 
varicocele  ;  5,  operations  for  varicocele,  especially  those  in  which  the  sper- 
matic artery  is  injured  ;  6,  elephantiasis  scroti ;  7,  injuries  of  the  head ; 
8,  injuiies  of  the  spine  ;  9,  blows  on  the  back  of  the  neck ;  10,  old*  age. 
Treatment. — Remove  the  cause  if  possible  ;  use  means  to  excite  the  arterial 
circulation  in  the  part,  and  to  support  the  veins.  Attend  to  general  health. 
In  some  cases  rest,  in  others  exercise  of  the  genital  organs  will  be  indi- 
cated. Prognosis  depends  on  cause  and  persistence.  In  genuine  cases, 
bad. 

Testicle,  Cancer  of. — Almost  always  encephaloid.  Pathology. — Begins 
usually  in  the  body  of  the  testis.  At  first  the  tubular  structure  of  the  tes- 
ticle is  spread  around  the  cancerous  mass,  not  mixed  with  it.  Cancerous 
mass  is  soft  and  pulpy,  generally  whitish  in  color  ;  cystic,  cartilaginous  and 
fibrous  masses  occasionally  interspersed.  Grow'th  usually  rapid.  Very 
little  tendency  to  ulcerate  through  skin.  Great  tendency  to  infection  of 
lumbar  glands.  Secondary  formations  occiu'  in  lungs  and  elsewhere.  In- 
guinal glands  sometimes  affected.  Signs. — A  solid  enlargement  of  the 
testicle,  progressing  rapidly,  without  inflammation,  is  almost  always  cancer. 
Testicle  smooth  and  firm,  till  localized  softening  occurs.  Pain,  dull. 
Sj)ecial  testicular  sensation  no  longer  evolved  by  pressure.  Cord  not  af- 
fected early.     General  health  perfectly  good  at  first.   Diagnosis. — The  first 


228  TESTICLE. 

thing  is  to  make  sure  that  the  enlargement  is  solid.  A  trocar  will  settle 
this  in  doubtful  cases.  (Vide  Hydrocele.)  Next,  a  diagnosis  has  to  be 
made  from  orchitis,  syphilitic,  scrofulous,  or  simple.  History,  concomi- 
tant symptoms,  and  the  effect  of  mercury,  pot.  iod.,  oleum  morrhuge,  etc., 
help  to  decide  this.  "  The  diagnosis  from  cystic  disease  may  be  based 
partly  upon  the  rate  of  growth,  but  especially  upon  the  information  elicited 
by  the  trocar."  (Humphry.)  Prognosis. — Usually  fatal  in  one  and  a  half 
to  two  years.  Many  cases  of  removal  without  recurrence  have  been  re- 
corded. Ti'eatment. — Unless  the  disease  has  spread  to  the  abdomen,  re- 
move the  testicle. 

Testicle,  Ctstio  Disease  of. — Pathology. — A  tumor,  consisting  of  multi- 
tudinous cysts  of  any  size  up  to  that  of  a  walnut,  with  thin  walls,  lined  by 
tesselated  epithelium,  and  containing  fluid  varying  in  consistence  from  that 
of  serum  to  an  almost  gelatinous  thickness.  At  least  three  views  as  to  the 
origin  of  the  cysts,  viz. :  (1)  dilatation  of  tubuli  seminiferi,  (2)  dilatation 
of  tubules  of  rete  testis,  (3)  a  fibrous  or  fibro-cartilaginous  tumor  in  the 
testicle,  with  more  or  less  of  cyst-formation  in  the  tumor.  The  cysts  are 
sometimes  "proliferating,"  containing  fibrous  or  cartilaginous  masses. 
Symptoms  and  Diagnosis. — Negative  symj)toms,  such  as  absence  of  j)ain,  of 
thickening  of  the  cord,  of  inflammation,  and  of  constitutional  disease,  to- 
gether with  positive  symptoms,  such  as  smoothness,  oval  or  spherical  form, 
and  slow  growth,  generally  reduce  the  final  diagnosis  to  a  distinction  from 
hydrocele  or  hiematocele.  Cystic  disease  is  heavier  than  hydrocele,  fluc- 
tuates less,  and  is  non-transparent.  Moreover  the  testicular  sensation  usu- 
ally remains  and  is  diffuse  owing  to  the  granular  substance  being  present 
on  every  side  of  the  tumor.  In  hydrocele  and  hseniatocele,  this  sensation 
is,  of  course,  confined  to  the  seat  of  the  testicle.  A  good  sized  trocar  is 
usually  employed  to  settle  the  question.  Treatment. — Castration.  But  if 
a  patient  has  only  one  testicle,  a  less  radical  operation  may  be  considered. 

Note. — Cystic  disease  is  sometimes  associated  not  only  with  enchon- 
droma,  but  with  recurrent  sarcoma  and  with  soft  carcinoma. 

Testicle,  Ijvipekfect  Development  of,  may  occur,  affecting  either  the 
body  of  the  gland  or  the  epididymis,  or  both.  So  also  part  of  or  even  all 
the  vas  deferens  may  be  absent,  the  testicle  being  present  and  even  full- 
sized.  Such  cases  may  be  virile,  though  necessarily  sterile.  Another 
form  of  imperfect  development  will  be  noticed  under  heading  Malposition. 

Testicle,  Enchondboma  of. — Usually  associated  with  cystic  disease, 
sometimes  with  soft  cancer,  the  small  masses  of  cai-tilage  growing  into  the 
cysts.  ?  as  to  whether  growths  commence  in  lymphatics  or  in  tubuli  of  the 
gland.  Appearances,  naked-eye  and  microscopic,  much  like  those  of  hya- 
line cartilage.*  Diagnosis. — Characteristic  weight  and  hardness.  Treat- 
ment.— Excision. 

'  Mr.  Savory  once  observed  of  a  section  of  a  lovely  specimen,  "like  pearls,  only 
raore  precious." 


*  TESTICLE.  229 

Testicle,  Fibbotjs  and  Fibro-cellular  Tumors  of. — Very  rare.  Kefer,  if 
necessary,  to  Curling  or  Humi)liry. 

Hernia  Testis. — The  condition  in  which,  as  a  result  usually  of  abscess, 
but  sometimes  of  wound,  the  whole  or  a  part  of  the  tubular  part  of  the 
o-land  escapes  through  an  aperture  in  the  tunica  albuginea,  and  through  a 
corresponding  opening  in  the  scrotum.  Any  form  of  chronic  orchitis  may 
lead  to  hernia  testis.  The  projection  looks  Hke  a  mass  of  granulations. 
Both  the  tubuli  and  the  margins  of  the  opening  through  which  they  pro- 
trude are  thickened  by  fibrous  deposits.  Treatment.— Cle&nliness,  rest, 
unguent,  hydrargyri  oxidi  rubri  or  ung.  hydrarg.  nitrat.  locally,  or  strap- 
ping, combined  with  appropriate  general  treatment,  usually  cause  the  skin 
to  cicatrize  over.  In  more  obstinate  cases,  try  incision  of  constricting 
edge  of  tunica  albuginea  (Pagan,  of  Glasgow),  or,  after  slitting  up  all  si- 
nuses, the  edge  of  the  skin  wound  may  be  freshened  and  brought  together 
over  the  protrusion  (Syme).  Anything  like  paring  off  protrusion  rarely 
necessaiy  and  usually  mischievous. 

Testicle,  Inflammation  of  (Orchitis  and  Epididymitis.) — Varieties. — 1, 
Acute  ;  2,  Chronic.  A  list  of  sub-varieties  might  be  made  out,  founded  on 
the  etiology,  e.g.,  gonorrhoeal,  traumatic,  syphilitic,  scrofulous,  metastatic, 
etc.     ( Vide  Strumous  Testicle  and  Syphilitic  Testicle.) 

Acute  Orchitis  (Inflammation  of  the  body  of  the  testicle). — Causes. — 
Blows,  wounds,  metastasis  (mumps),  and  rheumatism.  Symptoms. — Or- 
dinary signs  of  inflammation,  viz.,  pain,  tenderness,  heat,  redness,  swelling. 
Effusion  into  tunica  vaginalis.  When  accompanying  mumps,  it  begins 
about  fifth  or  sixth  day.  Treatment. — Eest,  suspensoiy  bandage,  cold  lo- 
tions, aperients,  antimony  (antim.  potass,  tart.,  gr.  j.,  aquae  fervent.,  § 
viii. ;  3  j.  4*'^  hortis).  Leeches  :  they  should  be  placed  over  the  cord  (Hum- 
phry). Punctui-e  of  tunica  vaginalis,  or  even  of  testicle,  with  a  sharp,  nar- 
row-bladed  knife. 

Acute  Epididymitis. — Frequently,  though  not  quite  accurately,  termed 
"  acute  orchitis."  Causes. — Mostly  gonorrhoea.  Any  urethral  irritation, 
e.g.,  stricture,  catheterization,  lithotomy,  impacted  calculus.  Blows. 
Rheumatism,  gout.  Epididymitis  may  supervene  during  any  stage  of  a 
gonorrhoea.  Symptoms. — Tenderness,  pain,  swelling,  and  hardness  of  epi- 
didymis. Effusion  into  tunica  vaginaUs.  Skin  reddened  and  tender.  Con- 
stitutional disturbance,  fever,  sickness.  Resolution  usually  commences 
within  a  fortnight,  but  thickening  may  persist  for  months.  Treatment. 
{See  Acute  Orchitis.) — Worth  while  to  persist  with  treatment  in  or  to  re- 
,  move  the  residual  thickening,  as  the  latter,  if  left,  may  interfere  with  func- 
tion of  testicle.  Suspensory  bandage,  moderation  in  all  things,  and,  ex- 
perimentally, pot.  iod.  internally. 

Chronic  Orchitis. — Causes. — (1)  acute  orchitis  ;  (2)  syphilis  ;  (3)  struma  ; 
(4)  injuries.  Acute  inflammation  in  the  testicle,  as  elsewhere,  sometimes 
subsides  into  chronic.     Most  cases  of  chronic  orchitis  are  syphilitic  and 


230 


TESTICLE. 


very  indolent.     {See  Stbumous    Testicle  and   Syphilitic   Testicle.)     The 
treatment  for  syphilitic  is  adapted  also  for  non-specific,  chi'onic  orchitis. 

Testicle,  Injueies  of.— Blows  cause  intense  shock.  MobiHty  of  testi- 
cle and  strength  of  tunica  vaginaHs  greatly  protect  testicle.  Extravasa- 
tion into  cord  may  extend  up  to  kidney,  or  even  higher.  Chronic, 
and,  more  rai-ely,  acute  orchitis  may  supei-vene.  This  orchitis  may  hope- 
lessly damage  organ.  Treatment.— Ai^^lj  general  principles.  Testi- 
cles bear  incised  wounds  well.  Kecovery  fi-om  self-mutilation  usually 
rapid. 

Testicle,  Inversion  of.— When  testicle  lies  in  front  of,  instead  of  at 
back  of,  scrotum,  it  is  Hable  to  be  injured  in  tapping  a  hydrocele. 

Testicle,  Other  Forms  of  Malposition  of,  are  known  as  :  1,  retained 
testicle ;  2,  descent  of  testicle  into  perinseum ;  3,  descent  of  testicle  into 
groin.  The  testicle  in  the  perinseum  is  liable  to  injury,  especially  dui-ing 
riding.  Operations  to  restore  it  to  the  scrotum  have  been  j^erformed  by 
Adams  and  by  Annandale.  An  undescended  testicle  may  remain  above 
the  internal  abdominal  ring,  or  may  enter  the  inguinal  canal.  Size  and 
maturity  of  gland  then  sometimes  imperfect ;  but  impotence  not  neces- 
sary, and  perha^js  not  usual,  even  when  both  glands  are  retained.  Liabil- 
ity to  certain  accidents,  e.g.,  (1)  inflammation,  which  may  be  confounded 
with  strangulated  hernia  or  with  bubo  ;  (2)  attacks  of  severe  pain  owing 
to  testicles  being  suddenly  "trapped"  between  abdominal  facile  ;  (3)  en- 
cysted hydrocele  ;  (4)  complication  with  congenital  hernia  frequent.  Ex- 
cessively troublesome  testicles  in  inguinal  canal  have  been  excised.  Treat- 
ment.— "VMien  a  hernia  adherent  to  testicle  threatens  to  descend  with  it, 
both  had  better  be  kept  in  abdomen  by  a  truss.  When  a  non-adher- 
ent congenital  hernia  exists,  apply  a  truss  above  testicle  and  below  her- 
nia ;  or,  if  testicle  is  still  in  abdomen,  dispense  with  truss  for  a  while 
in  the  hope  that  it  may  descend.  Be  in  no  hurry  to  operate  upon  a 
hydi'ocele  of  the  testicle  in  the  inguinal  canal.  Eemember  that  tunica 
vaginalis  cavity  usually  in  these  cases  communicates  with  that  of  jjerito- 
neum. 

Testicle,  Neuralgia  of  (with  which  may  be  associated  "irritability,"  or 
"  hypersesthesia,"  or  tenderness  of  the  testicle  ;  although  this  condition  may 
exist  separately).  Causes  and  Pathology. — (1)  reflex  ;  (2)  the  obscure  state 
of  the  nerves  and  vessels  of  a  j)art  commonly  associated  with  neuralgia 
elsewhere,  and  manifested  chiefly  by  signs  of  congestion  ;  (3)  in  some 
rare  cases,  the  presence  of  coarse  organic  disease,  e.g.,  chronic  abscess 
{vide  specimen  in  Htmterian  Museum)  ;  (4)  malaria.  Reflex  neuralgia  re-  ^ 
suits  from  stone  in  ttie  bladder  or  kidney,  from  varicocele,  indigestion,  etc. 
The  age  most  subject  is  the  period  of  puberty  and  the  next  ten  yeai's.  The 
exciting  cause,  frequently,  imdue  excitement  of  the  genital  organs.  Prog- 
nosis.— Time  almost  invariably  works  a  spontaneous  cure,  both  of  the  in- 
dividual attack  and  of  the  disposition  to  it.     Remove  the  cause.     Treat 


TESTICLE.  231 

vai'icocele,  indigestion,  etc.  Suspensory  bandage, '  cold  bath,  moderation  in 
diet  and  in  exercise  of  gland,  etc.  Quinine  for  intermittent  cases.  Hy- 
podei-mic  injection  of  morphia  (quarter  grain).  Horizontal  position,  or 
elevation  of  pelvis  and  lovs^er  extremities. 

Strumous  Testicle. — Causes.  {Vide  Scrofula.)  Pathology. — A  deposit 
of  tuberculous  matter  takes  place  within  the  convoluted  tubes  of  the  epi- 
didymis. This  matter  is  probably  at  first  mainly  a  collection  of  epithelial 
cells.  Subsequent  change  into  a  cheesy  or  into  a  calcareous  mass.  In 
the  meantime  chronic  inflammation  tends  to  destroy  the  walls  of  the  tubes, 
and  to  connect  the  tubercle  into  one  mass.  Color  of  tubercle,  white  or 
yellowish  white.  *  Disease  usually  begins  in  epididymis,  but  when  it  com- 
mences in  the  body  of  the  gland,  small,  scattered  gray  tubercles  first  ap- 
pear. These  enlarge,  and  coalesce  in  parts  of  the  gland.  The  ordinary- 
processes  of  chronic  inflammation  occur  around  the  deposits.  These  usu- 
ally result  in  formation  of  abscesses  and  sinuses.  Vas  deferens  usually 
thickened.  Both  testicles  often  affected.  Coincident  disease  of  lungs 
frequent,  and  of  kidney,  prostate,  vesiculse  seminales,  etc.,  occasional.  Signs. 
— Epididymis  and  sometimes  body  of  gland  enlarge  slowly  ;  very  little 
pain,  excex^t  when  an  abscess  is  ripening.  Formation  of  abscesses.  Thick- 
ening of  vas  deferens.  Scrofulous  appearance  of  patient.  Sometimes  co- 
incident disease  of  lungs,  etc.  Any  ordinary  affection  of  testicle  may  be 
the  commencement  of  stiaimous  disease  in  a  strumous  person.  Prognosis. 
— "With  suitable  treatment,  many  cases  make  a  satisfactory  recovery,  the 
tubercle  degenerating  and  becoming  encapsuled,  or  discharged.  Treatment. 
(FicZe  Scrofula.) — Suspensory  bandage,  cold  sponging  in  indolent  cases, 
iodine  externally.  Lay  open  and  clean  obstinate  sinuses.  Only  in  thor- 
oughly hopeless  cases,  such  as  resist  treatment  and  obviously  undermine 
the  health,  is  excision  justifiable.     (Vtde  Hekota  Testis.) 

Testicle,  Syphilitic. — A  tertiary  manifestation.  Pathology. —  (Com- 
pare with  Strumous  Testicle.  See  above.)  Generally  confined  to  body  of 
gland,  epididymis  and  cord  remaining  healthy.  Deposit  of  lymph  in  areo- 
lar tissue  between  the  tubules,  sometimes  in  nodules.  Different  lobules 
affected  in  different  degrees  usually.  Lymph-nodules  upon  tunica  albu- 
ginea.  Disease  sometimes  spreads  to  tubuli.  Tendency  to  fibrous 
degeneration,  eventual  contraction,  aud  even  atrophy  of  the  affected 
gland.  Both  testicles  often  attacked,  usually  one  after  the  other.  Liability 
to  abscess  and  hernia  testis.  Symptoms. — Enlargement,  usually  slow. 
Amount  of  pain  depends  directly  on  rapidity  of  progress.  Frequently 
neither  pain  nor  tenderness.  Stony  hardness.  Knotty  feel  (not  always). 
Epididymis  not  usually  distinguishable  from  rest  of  gland.  Hydrocele 
often  coexists.  History  of  syphilis  :  perhaps  other  collateral  symptoms, 
e.g.,  nodes.    Diagnosis. — Compare  sjonptoms,  as  given  above,  of  strumous 

'  See  Varicocele. 


232  TETANUS. 

testicle.  Chronic  orcliitis  caused  by  injuiy,  or  by  stricture,  can  scarcely 
be  distinguished  from  syphilitic,  except  by  the  history  and  general  symp- 
toms. But  it  requires  similar  treatment.  Prognosis. — Danger  of  atrophy. 
Liabihty  to  relapse.  Quite  under  control  of  antisyphilitic  remedies. 
Treatment. — Support  by  strapping  may  be  employed,  unless  suppuration 
be  progressing.  Suspensoiy  bandage.  Iodine  or  mercurial  ointment 
locally  when  pressure  is  not  advisable.  Open  abscesses  early.  Give  iodide 
of  potassium  internally,  or  order  mercurial  inunctions.     {See  Syphilis.) 

Tetanus. — Causes. — 1,  wound  ;  2,  catching  cold  ;  3,  race  ;  4,  male 
sex.  Wounds  in  which  nerves  are  lacerated  or  left  in  contact  with  sharp 
spiculse  of  bones  or  with  foreign  bodies,  and  wounds  of  the  hand  or  foot, 
ai-e  said  to  be  especially  hable.  Tetanus  is  a  more  common  complication 
of  compound  fractures  than  of  surgical  operations.  Exposure  to  cold  or 
sudden  change  of  temperature  rarely  acts  without  a  pre-existing  wound. 
Xegro  race  is  very  subject.  Pathology. — Richardson,  Billroth,  and  others 
teach  that  it  is  a  zymotic  disease,  i.e.,  a  poisoning  of  the  blood  through  the 
absorption  of  septic  material,  which  septic  material  is  formed  by  decom- 
position in  the  wound.  Brown-Sequard  and  many  others  regard  tetanus 
as  an  affection  of  the  spinal  cord  which  has  spread  from  some  irritated 
sensory  nerve  or  nerves  in  the  wound,  when  there  is  one.  In  favor  of 
the  latter  theory  may  be  cited  cases  in  which  the  sj)asm  has  been  con- 
fined to  the  iujiu'ed  side  of  the  body,  or  even  to  the  injured  limb  itself. 
Often  no  post-mortem  appearances  have  been  seen  in  the  cord ;  sometimes 
softening  of  the  central  gray  matter.  It  has  been  truly  observed  that 
great  changes  ought  not  to  be  expected,  becaiise  "  it  would  be  quite  im- 
possible for  motor  impulses  to  originate  from  a  spinal  marrow  reduced  to  a 
mass  of  debris."  Coats  {see  "  Med.  Chi.  Trans.,"  vol.  Ixi.)  observed  changes  in 
medulla  oblongata  like  those  in  cord,  and  even  a  morbid  condition  of  the 
motor  regions  of  the  convolutions.  There  was  an  accumulation  of  leuco- 
cytes round  the  vessels  of  the  medulla,  of  the  cord,  and  of  the  kidneys,  which 
in  his  opinion  supj^orted  the  theory  of  a  poison  circulating  in  the  blood. 
Symptoms  and  Course. — Ty^iical  case  :  A  man  with  comjDound  fracture 
of  forearm,  about  three  or  four  days  after  the  accident  complains  of  pain 
in  the  part,  and  is  rather  feverish.  The  next  morning  his  neck  is  stiff  and 
his  jaw  also  :  he  thinks  he  has  caught  rheumatism  in  that  region.  Within 
twenty-four  hours  short  spasms  of  the  back  occur  when  the  patient  is 
momentarily  exposed  or  fed,  or  otherwise  excited.  The  spasms  rapidly 
affect  also  the  abdomen  and  the  extremities  ;  and  now,  instead  of  being 
merely  transitory,  as  at  first,  they  never  wholly  pass  away,  the  abdomen 
feels  hard  like  a  board,  the  back  is  arched  (opisthotonos),  the  hands  are 
clenched,  the  face  marked  by  the  risus  sardonicus,  and  the  jaw  much  more 
fixed  than  before.  Skin  bathed  in  perspiration.  Temperature  raised  to 
about  100°.  Bowels  constipated.  Respiration  impeded  by  stiffiiess  of 
respiratory  muscles  (chest  feels  "  as  if  in  a  vice  "),  intellect  quite  clear,  no 


TETANUS. 


233 


sleep  ;  pain  in  tlie  muscles,  becoming  intense  when  the  spasms  are  aggra- 
vated. Slight  noises,  draughts,  and  other  trifling  irritants  cause  the 
tetanic  spasms  to  be  suddenly  trebled  in  force.  Dm-ing  one  such  par- 
oxysm, patient  dies  asphyxiated.  Or  he  lingers  on  for  a  few  days  or  a 
week,  and  perishes  of  gradual  asphyxia  (carbonic-acid  poisoning)  or  of  ex- 
haustion. Such  is  the  course  of  acute  tetanus,  and  traumatic  tetanus  is 
usually  acute.  But  the  disease  is  sometimes  chronic,  especially  if  it  be 
idiopathic.  Then  all  the  symptoms  are  less  severe,  the  patient  is  able  to 
take  a  fair  amount  of  nourishment,  and  gets  some  sleep.  His  breathing  is 
not  seriously  interfered  with,  and  he  has  considerable  chance  of  recovery. 
There  are  intermediate  grades  of  severity  of  every  shade.  Expression  of 
face  called  risus  sardonicus  arises  from  contemporary  spasm  of  all  the 
muscles  of  the  face  ;  dilators,  compressors,  levators,  depressors,  altogether. 
Thus  every  line  is  deepened  and  every  feature  fixed  by  its  muscles,  just 
as  a  ship's  mast  is  by  its  stays.  This  expression  may  persist  long  after 
otherwise  perfect  recovery.  Sometimes  the  trunk  is  arched  forward  (em- 
prosthotonos)  or  sideways  (pleurosthotonos). 

Tetakus  Neonatoeum  is  attributed  to  the  wound  caused  by  dividing  the 
umbilical  cord.  It  is  first  observed  by  the  mother  or  nurse,  in  consequence 
of  the  lock-jaw  preventing  entrance  of  finger  or  nipple  into  mouth.  Course 
presents  nothing  peculiar.     Alriaost  always  fatal. 

Diagnosis  of  tetanus  from  (1)  strychnia-poisoning,  (2)  hydrophobia, 
(3)  hysteria,  (4)  rheumatism. — Strychnia-poisoning  is  much  more  rapid, 
both  in  its  onset  and  in  its  advance  to  a  fatal  result.  The  paroxysms  of 
spasm  are  interrupted  by  periods  of  complete  relaxation.  Hence  there  is 
no  continuous  lock-jaw.  Death  almost  always  takes  place  within  two 
hours,  at  latest.  In  tetanus,  the  most  rapid  death  on  record  was  after  four 
hours'  duration.  Hydi-ophobia.  See  following  table  (abbreviated  and 
slightly  modified  from  Poland) : 


Tetanus. 
1.  Spasms  continued  (tonic). 

3.  Cause — wound,  or  exposure  to  cold. 
8.  Appears  generally  soon  after  injury. 

4.  Risus  sardonicus. 


6.  Frequently  gastric  pain,  but  no  vomit- 
ing. 


Hydrophobia. 

1.  Intervals  of  complete  relaxation  (spasms 

clonic). 

2.  Bite  of  a  rabid  animal. 

3.  Period  of  incubation  usually  a  month  or 

more. 

4.  Countenance  expressive  of  excitement, 

fearful  distress  and  peculiar  restless- 
ness; occasionally  frightfully  con- 
vulsed ;  eyes  bright  and  glistening, 
but  at  times  suffused. 

5.  Thirst ;  often   aversion  to   fluids ;  dis- 

charge of  viscid  saliva. 

6.  Vomiting  and  gastric  pains. 

7.  Mind  becomes  delirious. 

8.  No  authentic  case  of  recovery. 

9.  Intolerant  sensibility  of  surface  and  or- 

gans of  sense. 


234  TOES. 

Prognosis. — Acute  traumatic  tetanus  almost  always  fatal.  Subacute 
traumatic  tetanus  often  recovers,  especially  if  it  does  not  appear  till  some 
time  after  the  wound,  and  progresses  slowly.  The  prognosis  is  favorable 
according  to  the  duration  of  the  disease.  Thus,  a  tetanus  which  has  en- 
dured three  weeks  is  extremely  likely  to  recover.  Idiopathic  and  chronic 
tetanus  have  a  favorable  prognosis.  The  longest  dvu-ation  of  any  recorded 
fatal  case  has  been  thirty -nine  days.  Treatment — Remove  every  source  of 
excitement,  keep  the  room  dark  and  silent,  lay  down  thick  carpets,  protect 
from  draughts  by  screens.  Cover  the  jDatient  with  light,  warm  clothing, 
so  as  to  encourage  copious  diaphoresis.  Examine  the  wound  very  carefully, 
if  one  exists.  Remove  any  foreign  body  or  splinter.  If  a  nerve  is  believed 
to  be  irritated,  a  portion  of  its  course  may  be  excised.  Those  who  regard 
tetanus  as  a  septic  poisoning  would  be  justified  in  taking  measures  to  make 
the  wound  antiseptic.  Amputation  has  been  done.  Many  drugs  have  been 
tried,  chiefly  anodynes  and  antisx^asmodics.  Most  surgeons  now  choose 
between  chloral,  morphia  subcutaneously,  opium  internally,  and  Calabar 
bean.  Cm-are.  Chloroform.  Quinine.  Ice-bags  to  spine.  Of  Calabar 
bean,  Gan-od  writes  :  "  In  tetanus,  enough  must  be  given  to  produce  the 
physiological  symptoms  of  the  di-ug.  One-third  gr.  of  the  extract,  rubbed 
up  with  10-15  mimims  of  water,  and  neutralized  with  a  little  carbonate  of 
soda,  may  be  injected  every  two  or  three  hours  subcutaneously,  where 
swallowing  causes  i)haryngeal  spasm.  If  given  by  the  stomach,  1  gr.  of  the 
extract  rubbed  up  with  a  little  weak  spirit.  According  to  Frazer,  Calabar 
bean  should  be  given  at  the  very  onset  of  the  attack,  for  the  contraction  of 
muscles  begets  a  substance  which  excites  muscular  contraction.  When 
Calabar  bean  is  given,  its  action  should  be  carefully  watched,  lest  the  res- 
piratory muscles  become  paralyzed  by  it.  Rational  indications,  derived 
from  the  post-mortem  evidences  of  hyper.'cmia,  etc.,  of  spinal  cord,  are 
to  give  belladonna,  and  to  employ  every  available  means  of  diminishing 
spinal  congestion  (Fitzgibbon,  Dublin  Medical  Journal,  March,  1877).  And 
also,  I  think,  if  the  wound  be  not  too  large,  to  swab  it  thoroughly  with 
pure  carbolic  acid.  The  patient  should  be  patiently  and  frequently  fed 
with  milk  and  the  strongest  beef-tea.  Tracheotomy  has  been  recom- 
mended when  there  is  a  tendency  to  laryngeal  spasm. 

Thorax. — See  Chest. 

Thrombosis. — See  Veins. 

Thumb  may  be  bifid,  or  it  may  be  double. 

Thumb,  Dislocation  of. — See  Dislocations. 

Thyroid. — See  Bkonchocele. 

Toes  may  be  hypertrophied,  be  webbed,  bifid,  or  supernumerary. 

Hammee-toe. — A  condition  in  which  the  last  phalanx  is  bent  perpen- 
dicularly downward.  If  necessary,  divide  subcutaneously,  opposite  sec- 
ond phalanx,  the  corresponding  digital  offset  of  plantar  fascia.  Doubtful 
whether  its  origin  be  a  nervous  contracture  or  the  pressure  of  tight  boots. 


TONGUE,    DISEASES    OF.  235 

Tongue,  Diseases  of. — With  a  view  to  facilitating  diagnosis  (a  rather 
difficult  task  to  the  student  of  tongue  diseases),  I  shall  adhere  to  the  fol- 
lowing analytical  classification,  which  starts  from  the  most  palpable  feature 
of  each  disease.  I.  Superficial  ulcerations — simple  ;  syphilitic  primary, 
secondary.  IE.  Deep  ulcerations — 1,  simple  ;  2,  syphilitic ;  3,  maHgnant. 
TTT.  Localized  swellings — abscess,  innocent  tumor  (very  rare),  nsevus,  gum- 
mata,  mahgnant.  IV.  General  swelhng — acute  inflammation,  congenital 
enlargement,  general  enlargement  secondary  to  other  diseases  of  tongnie 
or  of  digestive  tract.  V.  Non-ulcerative  supei-ficial  affections — psoriasis, 
ichthyosis,  papilloma. 

Tongue,  Siiviple  SupEKFiciAii  Ulcekations  of. — Cause. — Indigestion  ;  irri- 
tation of  sharp-edged  teeth.  Occasionally  aphthous  inflammation.  Diag- 
nosis.— No  induration,  or  at  least  no  marked  degree  of  it.  Ulcers  some- 
times multiple.  Tongue  frequently  red  and  glazed.  Corresponding  sharp 
edge  of  tooth  may  be  detected.  Signs  of  indigestion.  Pain  frequently. 
Absence  of  syphilitic  history  and  of  collateral  symptoms.  Tr'eatment. — 
File  sharp  teeth.  Touch  ulcer  with  silver  nitrate.  Purgatives.  Sodge 
bicarb.,  with  infus.  calumbse,  before  meals.  The  more  superficial  the  ul- 
ceration, the  more  likely  is  chlorate  of  potash  to  be  highly  useful. 

Tongue,  Supebficial  Syphilitic  Ulcekation  of  (Secondary  or  Tertiary). 
— Diagnosis. — Similar  ulcerations  on  sides  of  mouth  or  fauces.  Perhaps 
psoriasis  also  present.  No  such  marked  induration  as  is  common  in  can- 
cer. History  and  patient's  aspect  may  be  syphilitic.  Treatment. — Anti- 
syphilitic.  Locally,  gargarisma  nigra,  hydrarg.  c.  creta,  inhahng  calomel 
fumes  (5  grains  nightly).  Internally,  either  pot.  iod.  or  hydrarg.  perchlor. 
For  obstinate  syphilitic  ulcer  of  tongue,  Berkeley  Hill  recommends  a  pill 
of  iodoform,  gr.  .},  ext.  gentian,  gr.  1.^,  thi-ee  times  a  day. 

Peimaey  Ulcek  (Chancre)  of  Tongue  is  not  rmknown. 

Tongue,  Simple  Deep  TJlceeation  of. — Very  rare.  Diagnose  from  cancer 
and  sj'philis  chiefly  by  negative  signs,  especially  absence  of  induration. 
Tends  to  heal,  unless  phagedenic.  Treatment. — Vide  Simple  Superficial 
Ulceration. 

Tongue,  Deep  Syphilitic  Ulcerations  of  (Tertiary). — Causes. — Gumma- 
tous abscess  or  (rarely)  spread  of  superficial  ulcer.  Appearance. — A  deep 
ulcer  or  fissure,  with  abrupt  edges,  usually  toward  the  centre  of  the  tongue, 
sometimes  at  the  edge,  and  often  with  a  history  of  previous  tumor  or  swell- 
ing (gumma).  Speaking  of  gummata  of  the  tongue,  Mon-ant  Baker  says : 
"They  are  usually,  but  by  no  means  always,  multiple;  they  rarely  or 
never  lead  to  fixation  of  the  tongue,  or  to  salivation,  or  to  veiy  much  pain  ; 
and  they  are  vei-y  tolerant  of  pressure."  In  these  respects  they  contrast 
"with  cancer.  Treatment. — Antisyphilitic,  especially  pot.  iod.  (gr.  x.,  ter 
die). 

Tongue,  Malignant  Ulceration  of  (Epithelioma). — Causes  as  obscure  as 
those  of  cancer  elsewhere.     Chronic  irritation  of  sharp  teeth  doubtless  an 


236  TONGUE,    DISEASES   OF. 

occasional  factor.  Clay-pipes.  Most  frequent  in  males  and  in  late  middle 
age.  Commences  as  a  fissure  (rarely  as  a  wart).  Syphilitic  disease  said  to 
sometimes  pass  into  ej)itlielioma.  Diagnosis. — Distinguish  from  syphilitic 
ulceration  by  (1)  hardness  of  base  and  edges ;  (2)  absence  of  collateral " 
signs  of  syphihs ;  (3)  position — cancer  usually  begins  at  side  of  tongue, 
deep  syphilitic  ulcer  generally  lies  near  septum  ;  (4)  pain  is  greater  in 
cancer ;  (5)  glands  are  affected  earher  and  more  extensively,  and  eventu- 
ally form  a  huge,  hard  mass  in  cancer ;  (6)  fixation  of  tongue  from  can- 
cerous infiltration  ;  (7)  salivation.  Unfortunately,  in  the  very  cases  in 
which  diagnosis  is  most  difficult  and  most  important,  the  above  signs  may 
not  be  well  marked.  Hence  the  surgeon  sometimes  has  to  try  antisyph- 
ilitic  remedies  merely  because  he  does  not  know  whether  he  has  to  deal 
with  cancer  or  syphihs.  Tenderness — intolerance  of  Jirm  pressm-e  distin- 
guishes cancer,  and  the  characteristic  hardness  is  of  the  same  nature  as 
that  of  scu'rhus  mammse,  i.e.,  not  like  inflammatory  induration.  Progno- 
sis.—  Without  operation,  hopeless.  With  operation,  varies  fi'om  some 
hope  of  non-recun"ence  when  a  small  cancer  and  a  wide  margin  of  appar- 
ently healthy  tissue  is  excised,  to  the  cei-tainty  of  recui'rence  when  the 
conditions  are  reversed.  Treatment — ^If  diagnosis  be  doubtful,  try  large 
doses  of  pot.  iod.  (grs.  x.-xx.,  ter  die).  Draw  bad  teeth.  Forbid  smok- 
ing. Kegulate  diet.  Question  of  removal  depends  upon  extent  of  disease. 
If  removal  of  whole  tongue  wail  not  suffice  to  take  away  all  the  disease, 
treatment  must  be  palliative.  Kemoval  by  (1)  knife,  (2)  ecraseur,  (3)  gal- 
vanic cautery,  (4)  hgature,  (5)  Eichai'dson's  scissors.  Prefer  knife  for 
comparatively  Hmited  operations  ;  ecraseur  most  popular  in  extensive 
ones.  Remove  disease  of  anterior  part  of  tongue,  and  in  suitable  cases 
even  more  extensive  disease,  by  oj^erating  entii-ely  thi'ough  mouth.  In 
some  instances  the  whole  tongue  coidd  be  thus  removed  if  Sir  James  Pa- 
get's  advice  be  followed — to  pass  scissors  into  the  mouth  and  divide  the 
muscles  which  attach  the  tongue  to  the  jaw,  before  pulhng  forward  the 
tongue.  In  such  an  operation  the  galvanic  ecraseur,  very  deliberately 
used,  would  be  safest,  for  severe  hemorrhage  would  here  be  embarrassing. 
Various  plsCns  have  been  devised  for  giving  the  operator  more  room  to 
work  in,  especially  (1)  Nunneley's,  who  passes  the  ecraseur  chain  through 
a  wound  in  the  mylo-hyoid  space,  and  prevents  it  from  slipping  forward 
by  means  of  hare-lip  pins  piercing  the  base  of  the  tongue  well  behind  the 
disease.  (2)  Sedillot's,  who  divides  the  symphysis  of  the  jaw  (in  a  >  - 
shaped  manner  to  facihtate  correct  apposition  after  the  operation).  Of 
course  the  lower  lip  is  divided  also.  Sedillot's  incisions,  combined  with 
the  ecraseur,  form  the  plan  probably  most  frequently  used  for  extensive 
cases.  An  interdental  splint  might  be  useful  in  after-treatment  of  divided 
jaw.  (See  Lyons  :  "St.  Bartholomew's  Hospital  Eeports,"  1878.)  (3)  Sub- 
mental operation  (RegnoU's).  Broad  aiTow-shaped  incision  in  mylo-hyoid 
space,  through  which  tongue  is  dragged  previous  to  removal     Protect  fa- 


TONGUE,    DISEASES    OP.  267 

cial  arteries,  and  secure  Unguals  as  soon  as  divided.  (4)  T.  Smith's.  In- 
cision of  cheek  from  corner  of  mouth  outward.  (5)  Whitehead,  of  Man- 
chester, cuts  through  base  of  tongue  from  before  backward  slowly  with 
scissors,  looking  out  for  the  lingual  arteries.  {Lancet,  1880.)  In  aU 
operations  on  the  tongue,  a  stout  whij)-cord  ligature  through  middle  of  an- 
terior third,  metal  retractors,  and  a  simple  gag,  are  requii-ed.  Also  pre- 
pare for"  hemorrhage.  Use  Clover's  or  Mills'  method  of  anaesthesia  through 
a  tube.  {Lancet,  vol.  i.,  1879.)  Prognosis. — Quite  good  for  small  opera- 
tions. Grave  for  larger  ones.  Speech  returns  perfectly  in  former ;  dis- 
tinct, but  sadly  modified,  in  latter.  After-treatment. —  Feed  through 
oesophageal  tube  and  by  enemas  for  a  few  days.  Use  simple  gargles  to 
cleanse  mouth.  For  distressing  salivation — alum  and  pyrethrum  gargles. 
A  particularly  lengthy,  complete,  and  clear  account  of  operations  on  tongue 
is  to  be  found  in  Erichsen. 

Tongue,  Abscess. — Very  uncommon.  Causes. — Obstruction  of  mucous 
glands  ?  Syphilitic  gummata  ?  Foreign  body.  Make  an  exploratory 
puncture  to  clear  up  diagnosis. 

Tongue,  Innocent  Tumobs  of. — Very  rare.  Cysts  heneath  the  tongue 
are  common.     (Fi^e  Eanula.) 

Tongue,  N^vus  of. — Rare.  Treatment. — Like  that  of  naevus  elsewhere. 
But  if  it  cause  no  unpleasant  effects,  and  do  not  grow,  let  it  alone. 

Tongue,  Gummata  of. — Seldom  seen  before  stage  of  ulceration.  Vide 
Deep  Syphilitic  Ulcer  of  Tongue  (above) . 

Tongue,  Malignant  Tumor  of. —  Vide  Malignant  Ulceration  of  Tongue 
(above). 

Tongue,  Acute  Inflammation  of  (Acute  Glossitis). — Eare.  Causes. — 
Merctmal  salivation,  iodism,  injury,  unknown  influences.  Symptoms. — 
Swelling,  often  enormous.  Pain.  Salivation.  Danger  of  suffocation. 
Treatment. — Treat  cause.  Astringent  gargles.  Deep,  longitudinal,  dorsal 
incisions  in  severe  cases.  As  lower  surface  of  tongue  is  more  extensile 
than  upper,  the  former  tends  to  present  upward.  Bear  this  in  mind  while 
incising  (Wormald  and  Holmes  Coote).     Suppoi-t  strength. 

Tongue,  Congenital  Enlargement  of  (Macroglossia). — Very  rare.  Treat- 
ment.— Remove  V-shaped  piece  from  anterior  part  of  tongue,  and  bring 
flaps  together.  Use  ecraseur.  Remember  that  children  bear  hemorrhage 
badly.  Slight  enlargement  of  tongue  is  a  common  sign  of  constitutional 
disorder.     Treat  the  cause. 

Tongue,  Psoriasis  of. — Sometimes,  but  not  always,  syphilitic.  Whitish 
and  dry-looking  patches  on  the  tongue,  with  shallow  fissures.  Under  the 
microscope,  the  epithelial  layer  is  found  slightly  thickened,  but  the  papillae 
smaller  than  normal.  The  condition  should  be  compared  and  contrasted 
with  that  in  "chronic  superficial  glossitis"  (Fairlie  Clarke),  in  which,  ac- 
cording to  Butlin,  the  papillse  are  absent,  the  surface  almost  as  smooth  to 
the  microscope  as  to  the  naked  eye,  the  epidermis  thinned,  but  the  sub- 


2o8  TONSILS,    CHRONIC    ENLAEGEMENT    OF. 

epithelial  tissue  thickened  and  infiltrated  with  cells  ("Medico-Chirurgical 
Transactions,"  vol.  Ixi.). 

Tonsillitis,  Acute  (Quinsy). —  Causes. —  Predisijosing  are  chronic 
enlargement  and  depressing  influences,  e.g.,  dark,  damp  residences,  defec- 
tive drainage.  Exciting  cause,  usually  catching  cold.  Signs. — Pain  on 
swallowing,  at  first  slight,  but  gi-adually  increasing  in  some  cases  till  the 
act  of  deglutition  inflicts  a  pain  like  the  stab  of  a  knife.  Swelling  both 
internally  and  externally.  The  swelling  may  become  so  difiuse  that  the 
jaws  may  be  scarcely  separable.  When  suppuration  takes  place,  pain  usu- 
ally strikes  into  ear  and  becomes  throbbing.  Fluctuation  develops.  Foul 
tongue  (owing  to  oral  catarrh)  ;  offensive  breath  ;  fever — temperature  may 
rise  to  104°— and  slight  dehrium  for  one  or  two  nights  not  infrequent. 
Diagnosis. — Seldom  presents  difficulty,  except  when  the  mouth  will  not 
open.  Then,  upon  looking  carefully  at  the  patient,  it  will  be  seen  that  the 
swelling,  however  diffuse,  has  its  centre  below  and  beneath  the  angle  of  the 
jaw,  is  not  chiefly  in  front  of  and  below  the  ear  as  in  mumps,  or  over  the 
jaw  as  in  diffuse  inflammation  commencing  near  the  gums  and  teeth. 
]\Ioreover,  the  voice  is  generally  characteristically  guttural,  and  the  history 
clear  of  an  acute  course  commencing  in  the  throat.  It  is  to  be  remem- 
bered that  inflammation  of  the  tonsils  may  be  only  part  of  a  more  serious 
disease,  e.g.,  scarlatina  or  diphtheria.  Prognosis. — Tonsillitis  usually  affects 
those  accustomed  to  it,  and  who  generally  know  how,  by  a  little  care,  to 
check  it.  But  it  frequently  goes  on  to  suppiu-ation  ;  and  in  exceptional 
cases,  when  very  diffuse,  causes  death  by  exhaustion  or  by  suffocation. 
Treatment. — Prophylactic,  the  same  as  that  for  catarrhs  in  general.  In  ad- 
dition, do  not  wear  low  shirts  and  coUars,  especially  as  regards  the  night- 
dress. Wear  a  hght  wrapper  round  the  throat  when  out  at  night ;  avoid 
hot,  smothering  comforters.  Early  retii-ement  to  bed,  with  a  narrow  j)iece 
of  flannel  round  neck,  wiU  often  cut  short  a  sore-throat.  Gargling,  some- 
itimes  good,  is  often  more  irritating  than  useful.  Best  gargles  are  those  of 
capsicum,  of  guaiacum,  and  of  chlorate  of  potash.  Give  mist,  guaiaci.  or 
pot.  chlor.  ad  libitum,  internally.  When  swelling  is  very  great,  especially 
if  fluctuation  can  be  felt,  puncture  tonsil.  Use  a  bistoury  wrapped  in  lint, 
except  toward  the  point,  or  a  gum -lancet,  and  direct  its  edge  and  point 
somewhat  inward  {i.e.,  toward  median  plane  of  body  and  away  from  great 
vessels).  If  mouth  cannot  be  opened,  patient  must  simply  rest  in  bed, 
with  a  high  pillow,  in  a  rather  warm,  thoroughly  dry  room,  using  deriva- 
tives, such  as  hot  mustard  and  water  to  feet,  inhaling  the  steam  of  hot 
water,  with  a  little  creosote  dropped  in  it.  Hot  fomentations  may  be  ap- 
plied externally,  or  leeches  beneath  the  angle  of  the  jaw.  Do  not  forget 
that  leech-bites  leave  scars. 

Tonsils,  Chronic  Enlargement  of. — Common  in  scrofulous  chil- 
dren, especially  in  cold,  damp  chmates.  Pathology. — An  hypertroph}'  of 
both  glandular  and  fibro-ceUular  constituents  of  tonsil,  the  result  of  chronic 


TEACHEOTOMY,    INDICATIONS    FOR.  239 

inflammation.  Signs. — Visible  enlargement  of  tonsil.  Peculiar  throaty 
voice.  Occasionally  difficulty  of  breathing.  Mouth  usually  kept  oj)en ;  char- 
acteristic expression  of  face.  Deafness.  Extra  Uability  to  acute  and  sub- 
acute tonsillitis.  Prognosis. — Considerable  enlargement,  if  coming  on  be- 
fore puberty,  wOl  often  greatly  diminish  as  adult  life  is  approached,  but 
it  seldom  disappears  sjDontaueously  and  entirely.  Treatment. — For  severe 
cases  of  long  standing,  excision.  Other  cases  should  be  treated  as  j)haryn- 
gitis,  quod  vide.  Excision  of  Tonsil  may  be  effected  with  a  bistoury  and 
vxxlsellum  forceps.  In  using  tonsil-guillotine,  take  care  to  apply  it  with 
the  spear  or  hooks  toward  the  median  line  and  the  ring  next  the  tonsil. 
Pass  the  guillotine  into  the  pharynx  horizontally,  and  rotate  it  to  the  per- 
pendicular as  you  place  it  over  the  tonsil.  In  many  cases  the  tonsU  can  be 
pushed  into  the  guillotine  by  the  forefinger  of  the  left  hand  placed  outside 
the  neck. 

Torticollis.— /S'ee  Neck  (Wky-). 

Trachea,  Foreign  Bodies  in. — See  Laeynx,  Foreign  Bodies  m. 

Tracheotomy,  Indications  for. — 1.  Foreign  bodies  in  trachea  or 
bronchi  or  pharynx.  2.  Scalds  of  glottis  in  children.  3.  Very  advanced 
and  extensive  disease  of  larynx.  4.  Croup.  5.  Diphtheria  in  children. 
6.  As  a  preliminary  step  in  extensive  operations  on  and  about  the  jaws  and 
throat.  In  such  cases  the  anaesthetic  is  usually  administered  through  a 
tube  in  the  tracheal  opening.  At  the  same  time  the  glottis  may  be  shut 
off  fi-om  the  lungs  by  using  Trendelenburg's  "  trachea-tampon,"  thus  pre- 
venting any  blood  from  passing  down  the  trachea.  Operation. — Two  chief 
varieties,  viz.,  (1)  high  and  (2)  low,  respectively  above  and  below  isthmus 
of  thyroid ;  latter  not  usually  either  necessary  or  desu-able.  Instruments. — 
Scalpel,  dissecting  forceps,  artery  forceps,  bull-dog  forceps,  metal  retrac- 
tors, blunt  hook,  sharp  tracheotomy  hook,  cannulse  (Fuller's  bivalve  pref- 
erable at  first ;  Baker's  rabber  tubes  may  be  substituted  after  a  few  days). 
Lawson  recommends  the  bivalve  cannula  without  the  inner  tube.  Dur- 
ham's "  lobster-tail "  cannula  less  irritating  than  ordinary  metal  tube.  H. 
A.  Martin,  of  Boston,  U.  S.,  does  not  use  tubes  at  all.  (See  Dublin  Medical 
Journal,  September,  1878.)  Tape  to  tie  cannula  in  place.  Sponges,  liga- 
tures, gauze,  feather,  kettle,  curtains,  etc.,  the  latter  for  after-treatment. 
Patient  lies  on  his  back  ;  surgeon  stands  on  right  side.  Pillow  beneath 
neck,  head  back.  Get  best  light  possible.  Determine  exact  median  line 
by  seeing  and  feeling.  Feel  lower  border  of  cricoid  cartilage.  Incise  skin 
from  this  point  downwai'd  two  inches.  Avoiding  anterior  jugulars,  cut  in 
middle  line  carefully  down  to  trachea.  When  thyroid  isthmus  is  recog- 
nized, it  may,  if  necessary,  be  hooked  down  or  even  divided.  When  trachea 
is  reached,  it  can  easily  be  distinctly  felt.  Now  insert  sharp  hook  into 
trachea,  always  keeping  to  median  line.  Slightly  raise  trachea  with  this 
hook.  It  thus  becomes  defined,  and  can  be  incised  with  confidence. 
Tracheal  opening  to  be  perpendicular,  and  of  size  proportional  to  the  pa- 


240  TUBERCLE. 

tient's  and  to  that  of  the  cannula  to  be  used.  Always  keep  to  the  median 
line,  and  take  care  that  the  parts  are  not  displaced  laterally  by  the  retrac- 
tors. In  opening  trachea,  turn  edge  of  knife  upward.  After-treatment. — 
Usual  practice  is  to  surround  bed  with  curtains,  to  conduct  steam  of  a 
kettle  by  a  tube  to  within  the  curtains,  and  to  keep  the  room  at  a  tem- 
perature of  about  70°  Fahr.  But  some  sui-geons  {e.g.,  Lawson)  are  less 
particular  about  these  points,  preferiing  abundance  of  fi-esh  air.  Over  the 
tracheal  wound  place  a  sponge  or  a  fold  of  gauze.  From  time  to  time, 
when  the  patient  coughs,  assist  with  a  feather  to  clear  away  mucus  or 
false  membrane.  Twice  a  day,  or  oftener  if  necessary,  remove  inner  tube 
and  clean  it.  Surgeon  may  occasionally  remove  and  clean  outer  tube  with 
advantage.  This  must  frequently  be  done  if  inner  tube  is  not  used.  Sup- 
port strength  with  abundant  liquid  food,  milk,  beef-tea,  etc.  Of  course, 
when  cannula  has  to  be  kept  in  any  time,  it  does  not  prevent  retiu-n  to 
solid  food.  Insensitiveness  of  glottis  generally  supervenes,  and  allows 
part  of  food  to  trickle  into  larynx.  Complications. — (1)  Hemorrhage,  (2) 
bronchitis  and  pneumonia,  (3)  erysipelas. 

Trephining. — Indications  for  the  operation  are  given  under  Head,  In- 
juries OF.  The  operation  is  occasionally  done  for  cases  of  epilepsy,  in 
which  the  siu'geon  thinks  he  recognizes  signs  of  localized  mischief.  And 
it  is  likely  enough  that  the  labors  o\  Ferrier,  Fritz,  Hitzig,  Duret,  and 
others,  together  with  the  development  of  antiseptic  surgery,  may  lead  to 
fui'ther  co-operation  between  the  physician  and  the  surgeon  in  the  treat- 
ment of  cerebral  diseases.  Ojjei^ation. — Scalpel,  dissecting  forceps,  artery 
forceps,  trephine,  elevator,  piece  of  quill,  sxDonges,  antiseptic  dressings, 
sjDray,  etc.  Unless  bone  is  akeady  exposed  by  a  scalp-wound,  reflect  soft 
tissues  sufficiently  by  T-shaped  incision.  Adjust  trephine  so  that  the  pin 
shall  project  very  slightly  beyond  the  teeth.  If  there  be  a  fractui-e,  place 
the  pin  on  a  firm  edge  of  bone.  In  working  trephine,  take  care  to  press 
evenly  on  aU  sides,  lest  dura  mater  be  reached  on  one  side  before  other 
side  of  trephine  is  half  through.  As  dui-a  mater  is  aj^proached,  saw  very 
gently,  and  frequently  probe  with  the  piece  of  quill.  As  soon  as  this  de- 
tects diu-a  mater  on  one  side,  tilt  trej)hine  toward  other  side.  When  loose 
enough,  remove  disc  of  bone  with  elevator.  Dangers :  (1)  of  wounding 
dura  mater :  to  be  avoided  by  precautions  mentioned  above  ;  (2)  of  wound- 
ing a  sinus  or  large  arterial  branch  :  to  be  avoided  partly  by  some  precau- 
tions, but  chiefly  by  bearing  in  mind  anatomical  landmarks. 

Trochanter,  Injuries  of.  (Vide  Fkactuees  of  Femur.) — ^Prolonged 
weakness,  and  sometimes  permanent  atrophy,  occasionally  produced  by 
falls  upon  the  great  trochantei*,  even  without  fracture. 

Tubercle. — A  term  apphed  to  three  substances,  which  are  sometimes, 
but  not  always,  merely  thi-ee  forms  of  the  same  substance,  viz.,  (1)  "  mil- 
iary tubercles  " — small,  round,  transparent  or  semi-transparent  millet-seed- 
like nodules,  the  most  usual  seats  of  which  are  the  substance  of  the  lungs 


TUMOBS.  241 

and  the  surface  of  serous  membranes  ;  (2)  "  cheesy  "  or  "  cmde  "  tubercle 
— dry,  opaque,  cheesy  masses,  tending  either  to  soften  into  purulent,  cui"dy, 
creamy  fluid,  or  to  change  to  (3)  a  cretaceous  mass.  Forms  2  and  3 
may  be  results  of  the  metamorphosis  of  form  1.  But  they  may  also  be 
due  merely  to  changes  in  ordinary  inflammatory  products.  I  say  "  ordi- 
nary," because  it  is  believed  by  many  that  even  tubercle  is  sometimes  a 
product  of  inflammation.  That  the  presence  in  the  system  of  cheesy 
masses,  the  resvdt  of  inflammation,  predisposes  in  some  way  to  the  forma- 
tion of  miliary  tubercle,  is  pretty  generally  allowed.  (See  Scrofula  for 
treatment,  etc.) 

Tumors. — Definition, — Word  "tumor"  not  always  used  in  same  sense. 

(1)  Sm-geons  sometimes  use  it  loosely,  as  if  synonymous  with  "swelling  of 
undetermined  nature,"  as,  e.g.,  in  such  a  speech  as  this,  "  Examine  this  tu- 
mor and  teU  me  whether  you  think  it  is  an  aneurism  or  a  new  growth." 

(2)  The  usual  meaning  of  "  tumor"  is  an  abnormal  swelling  in  the  tissues, 
which  cannot  be  clearly  regarded  as  mere  inflammatory  new  formation,  or 
as  anem-ismal  dilatation  of  a  single  vessel.  The  mai-gins  of  this  definition 
are  necessarily  uncertain,  because  the  limits  of  the  process  of  inflammation 
are  not  quite  known.  Causes. — There  can  be  no  question  but  that  tumors 
do  frequently  arise  fx'om  continued  local  ii-ritation,  but  to  what  extent  he- 
reditary predisposition  acts  as  a  predisponent  is  not  yet  settled.  The  very 
common  idea  that  cancerous  tumors  are  almost  as  hereditary  as  Roman 
noses  is  certainly  wrong.  That  heredity  plays  no  part  in  theii-  production 
is  equally  incredible.  Why,  it  plays  an  unquestionable  part  in  the  produc- 
tion of  wooden  legs,  because  the  martial  spirit  v\-liich  has  exposed  his  in- 
ferior members  to  shot  and  shell  is  often  "  bequeathed  from  bleeding  sire  to 
son."  It  would  appear  fi-om  the  clinical  obseiwations  of  Sir  James  Paget, 
confirmed  by  the  microscopic  ones  of  IMr.  Butlin,  that  the  processes  of  in- 
flammatory new  formation,  of  ordinary  cellular  infiltration,  may  pass,  by  a 
gradual  commingling,  into  the  process  of  cancerous  infiltration  with  new 
cells  genetically  sprung  from  epithelium.  Often  also  cancer  is  seen  to  at- 
tack locahties  which  have  long  been  the  seat  of  syphilitic,  of  eczematous, 
or  of  some  other  chronic  fissui-e  or  ulceration.  It  is  possible  that  new 
growths  may  arise  from  irritation  in  a  quite  distant  part.  They  can  be  re- 
moved in  that  way.  I  have  seen  a  recurrent  tumor  over  the  scapula,  which 
had  shrunk  gradually  to  one-eighth  its  former  size  during  the  progress  of 
phthisis  and  fistula  in  ano.  Such  new  growths  as  elephantiasis  and  bron- 
chocele  j^roceed  fi'om  endemic,  perhaps  miasmatic  influences.  It  is  not 
impossible  that  malignant  tumors  are  contagious,  though  there  are  no  clin- 
ical proofs  of  it.  Considering  how  slow  most  cancers  are  to  infect  the  suf- 
ferer's own  system  (since  early  removal  often  effects  a  perfect  cure),  the 
absence  of  such  proofs  is  not  surprising.  Certain  localities  and  certain 
ages  are  specially  subject  to  certain  tumors  :  e.g.,  lower  lip  of  middle-aged 
to  epithelioma.     Sex  generally  acts  in  a  manner  easily  explained.     For  ex- 

16 


242  TUMORS. 

ample,  it  is  not  difficult  to  see  why  men  alone  should  have  epithelioma 
scroti,  women  alone  fibroid  of  the  uterus,  and  women  almost  the  monopoly 
of  tumors  of  the  breast.  Classification. — Fatty  tumor  ;  fibrous  tumor  ;  car- 
tilaginous tumor  ;  osseous  tumor ;  myoma ;  neiu'oma  ;  vascular  tumors  ; 
sarcoma  ;  lymphoma,  including  glioma ;  reciu-rent  fibroid  ;  fibro-ceUular 
tumor ;  myxoma,  etc.  ;  papilloma  ;  adenoma ;  cystic  tumors  ;  carcinoma. ' 
The  carcinomata,  with  most  sarcomata  and  certain  lymphomata,  are  often 
classed  together  as  malignant,  the  rest  being  termed  innocent.  Malignancy 
means  simply  endowed  with  a  tendency  to  infect  the  system.  In  diagnos- 
ing a  tumor,  the  most  important  question  to  answer  is  that  of  innocent  or 
malignant  ?    In  some  cases  this  is  the  only  practical  question. 

Fatty  Tumoes,  Lipomata. — Two  varieties,  viz. :  1,  Circumscribed  ;  2, 
Continuous.  The  common  fatty  tumor  belongs  to  the  former  variety. 
Best  example  of  continuous  Hpoma  is  excessive  double  chin.  Cause. — 
Usually  unknown.  Sometimes  follows  local  ii'ritation.  Rarely  appears  in 
children  or  very  old  people.  Continuous  lii^oma  generally  begins  about 
age  of  forty.  Female  sex  most  liable.  Anatomy. — Common  fatty  tissue 
siuTOunded  by  a  fibrous  capsule  and  divided  into  lobes  by  fibrous  parti- 
tions. Sometimes  outlying  lobes  project  into  the  adjacent  parts.  Fibres 
connect  the  capsule  with  the  skin  and  cause  the  latter  to  dimple.  Signs. — 
Lipomata  are  soft,  elastic,  "pillowy,"  movable,  but  causing  the  skin  to 
dimple  as  they  move. '  Normally  without  pain  or  tenderness,  except  a  ht- 
tle  aching  from  mere  weight,  and,  in  a  few  cases,  a  little  pain,  ajjjDarently 
neuralgic.  Almost  always  single.  Occasionally  multij^le.  Bulk  uulim- 
ited,  even  up  to  50  lbs.  avoirdupois.  Multiple  fatty. tumors  rarely  grow 
to  more  than  one  inch  in  diameter.  Growth  slow.  Their  loose  con- 
nections often  jpermit  fatty  tumors  to  shift  their  positions  under  the 
influence  of  gra\ity.  They  are  liable  to  cystic,  cretaceous,  and  ulcerative 
degenerations.  Seat. — Chiefly  trunk  and  adjacent  parts  of  limbs.  Diagnosis. 
— When  there  is  no  cutaneous  dimi^ling  and  they  are  unusually  firm,  they 
may  be  mistaken  for  cysts,  or  for  fibrous  or  sarcomatous  tumors,  but  the 
mistake  is  of  no  consequence.  Treatment. — Let  the  continuous  lipoma 
alone,  unless  restricted  diet  and  judicious  exercise  will  benefit  it.  Or  give 
liq.  potass.,  TTL  x.,  ter  die,  for  a  long  time.  Other  single  fatty  tumors 
should  be  excised.  Cut  straight  down  upon  the  tumor,  or  into  it  if  you 
like,  and  then  dissect  or  tear  it  away  from  its  connections.  In  dressing 
the  wound,  attend  to  drainage  and  proper  adjustment  of  pressure  and 
support.  Multiple  fatty  tumors  should  be  let  alone  as  a  rule.  Lipomata 
are  occasionally  pendulous :  these  should  simply  be  cut  off. 

FrBEOus  Tumors.  Fibromata. — Anatomy. — Fibrous  tissue  variously  ar- 
ranged, sometunes  in  interlacing  bundles,  sometimes  in  concentric  circles. 
Arrangement  of  fibres  may  or  may  not  be  visible  to  the  naked  eye.    Section 

'  Paget  adds :  Neuralgic,  PulsatiBg,  Floating,  and  Phantom. 


TUMORS.  243 

whitisli  or  pale  red  in  color.  Consistence  generally  firm  and  elastic, 
sometimes  quite  soft.  Mucous  softening,  serous  infiltration,  calcification, 
even  tme  ossification  not  rare.  Large  cysts  may  form.  Sarcomatous  tissue 
(round  or  spindle  cells)  fi'equently  mixed  with  the  fibres — "fibro-sarco- 
mata."  Vascularity  usually  low.  Seats. — Usually  uterus,  bones,  nerves, 
cellular  tissue  near  joints,  sheaths  of  tendons,  testicles,  and  ear-lobules. 
Characters. — Rounded  or  modelled  to  surrounding  parts,  smooth,  non- 
lobed,  firm,  resistant,  elastic,  generally  hard,  occasionally  soft.  Of  course 
degeneration  alters  their  physical  jDroperties.  Growth  slow.  Size  unlimited. 
Pain  absent.  Commence  in  middle  life.  Those  connected  with  nerves  or 
bones  sometimes  commence  in  the  young  (after  jDuberty).  Number : 
periosteal  fibromata  usually  solitary  ;  but  uterine  and  neuromatous  fibroids, 
especially  the  latter,  are  more  ofteu  multiple.  Diagnosis. — "Consistence, 
locaUty,  age,  mode  of  attachment  and  form  of  the  tumor  almost  always 
lead  to  its  correct  recognition."  Treatment. — Remove  thoroughly.  Uterine 
fibroids  requh-e  special  consideration,  and  are  neither  to  be  rashly  inter- 
fered with  nor  supinely  let  alone.  Recurrence. — Piu-e  fibroma  probably 
only  recurs  when  excision  has  been  incomplete.  But  fibro-sarcomata  may 
infect  the  system. 

CARTniAGiNOus  TuMOR — ExcHONDRoiiA. — Anatomy. — Resembles  some- 
times hyaline  and  sometimes  fibro -cartilage.  But  pathological  differs  from 
normal  cartilage  in  three  respects,  viz.,  (l)it  is  traversed  by  "capsular-like" 
communicating  connective-tissue  meshes ;  (2)  these  meshes  are  usually 
vascular,  while  normal  cartilage  has  no  vessels  ;  (3)  the  intercellular  sub- 
stance may  be  gelatinous  or  fi'iable.  The  section  cuts  gi'istly  and  is  bluish 
or  yellowish  white,  or  the  tumor  may  be  softened  or  degenerated.  Locality. 
—Chiefly  the  bones :  metacarpals  and  phalanges  of  hand  ;  femur,  pelvis, 
etc.;  parotids,  testicles,  ovaries,  breasts,  other  glands.  Frequently  mixed 
with  other  tumors.  Age. — Youth.  "The  younger  the  age  at  which  a  tu- 
mor of  bone  begins,  the  more  it  is  likely  to  be  cartilaginous,  if  its  general 
characters  agi-ee  therewith  "  (Paget).  Characters. — Hard,  nodular,  incom- 
pressible, or  perhaps  very  slightly  compressible,  with  a  veiy  quick  elastic 
recoil.  Rarely  soft,  but  even  then  very  elastic.  Rate  of  gi'owth  not  charac- 
teristic. Size  variable.  Coincident  ossification  often  occurs  and  alters  char- 
acter of  tumor.  Diagnosis. — Consider  carefully  locality,  age,  and  rate  of 
gi-owth.  Prognosis. — Purely  cartilaginous  tumors  are  as  innocent  and  non- 
recm-rent  as  any  class  of  tumors.  Treatment. — See  Eijchondkoma  of  Bones, 
OF  Parotid  Gland,  and  of  Testicle. 

Osseous  Tumors  ;  Osteomata. — See  Exostoses. 

Myoma. — A  tumor  consisting  of  muscle-ceUs  or  fibres.  Pure  myomata 
are  unknown ;  but  muscular  elements,  both  striped  and  unstriped,  occa- 
sionally are  found  in  fibromata. 

Neuroma. — The  surgeon  often  applies  this  term  to  any  tumor  situated 
on  a  nerve  ;  the  strict  pathologist  confines  it  to  a  tumor  consisting  mainly 


244  TUMOES. 

of  nerve-filaments  or  substance.  The  latter,  so-called  "  true  neuromata," 
are  very  rare,  most  tumors  growing  on  nerves  being  fibromata,  or  fibro- 
sarcomata.  Usually  multiple,  often  recurrent.  Excision  without  injtuy 
to  nerve  itself  rarely  possible.  As  a  rule  best  let  alone.  A  traumatic  neii- 
royna  is  the  bulbous  end  of  a  divided  nerve.     When  painful,  excise. 

Vasculae  Tumors — Angioivuta^N^vi — Ebectile  Tumors. — Definition. — 
Tumors  composed  almost  exclusively  of  vessels  held  together  by  a  slight 
amount  of  connective  tissue.  Varieties. — Three  :  (1)  cajDillary,  including 
common  nsevi  and  "  port- wine  stains ;"  (2)  venous,  or  cavernous  angio- 
mata ;  (3)  arterial,  or  pulsating,  erectile  tumors ;  with  which  may  be 
j)laced  "  aneurism  by  anastomosis."  Etiology. — Many  are  congenital  (es- 
pecially the  first  kind).  The  others  usually  commence  in  early  childhood, 
excepting  aneurism  by  anastomosis,  which  often  develops  in  young  people, 
after  injuries.  Anatomy. — (1)  Capillary  angioma  consists  of  a  mass  of  di- 
lated capillaries,  arranged  in  lobuli,  each  of  which  corresponds  to  the 
blood-supply  of  a  single  hair  or  cutaneous  gland.  The  whole  mass  is  of 
any  size  from  a  pin's  head  to  a  sixpence  or  a  penny,  or  a  much  larger  space, 
and  of  varying  though  usually  trifling  thickness.  Color  from  deep  red 
to  slaty  blue.  But  sometimes  the  skin  itself  is  not  involved,  and  it  then 
may  be  of  normal  color.  Eedness  disappears  under  pressure,  so  also  does 
part  of  thickness  of  tumor  when  there  is  any  perceptible  thickness.  Cap- 
sule, more  or  less  defined.  (2)  Cavei-nous  angioma  consists  of  an  assem- 
blage of  spaces  filled  with  blood  and  resembling  dilated  veins,  or,  more 
accui'ately,  the  corpus  cavernosum  penis.  In  some  of  the  spaces,  chalky 
"  vein  stones "  may  be  found.  (3)  Aneiu'ism  by  anastomosis,  or  cii'soid 
aneurism,  is  a  convolution  of  dilated  and  elongated  arteries.  Signs. — 
Port-wine  stains  and  ordinary  nsevi  are  easily  recognized  by  their  color, 
and  theu'  congenital  or  early  origin.  AH  piu-ely  vascular  tumors  are  more 
or  less  soft  and  compressible.  The  venous  ones  dilate  during  forced  ex- 
piration. The  arterial  j)ulsate.  Seats. — Mostly  subcutaneous  tissue  of 
scalp,  face,  and  trunk.  Venous  tumors  not  unfrequently  occur  more 
deeply,  especially  in  orbit,  tongue,  inter-muscular  sjDaces,  and  even  in  the 
liver.  Degeneration,  especially  cystic,  may  occur.  Number  of  nsevi  in  an 
infant  often  multiple.  Diagnosis. — Rarely  presents  any  difl&culty  except  in 
the  deeper  venous  and  capillaiy  tumors.  These  may  be  confounded  with 
lipomata  or  cysts ;  but  the  possibility  of  partially  or  wholly  emptying  them, 
and  the  effect  on  them  of  forcible  expii-ation,  will  often  settle  the  question. 
Prognosis. — If  let  alone,  they  will  occasionally  progress  till  they  cause  de- 
formity, weakness,  and  the  absorption  even  of  important  parts.  But  they 
frequently  remain  stationaiy,  or  may  even  retrograde.  Treatment. — 1.  By 
injection  of  tinct.  ferri  perchlor.;  dangerous,  especially  in  naevi  of  head  and 
neck.  2.  By  galvano-caustic,  benzoline  cautery,  bulbous  n^evus  cautery, 
small  sticks  of  lunar  caustic  driven  into  tumor.  3.  By  nitric  acid  (best  for 
small  and  superficial  njevi).    4.  Byhgature:  various  modes,  subcutaneous 


TUMORS.  245 

and  otherwise.  5.  By  compression.  6.  By  excision.  Before  excision^  the 
base  of  the  nsevus  may  be  surrounded  by  an  elastic  Hgature,  which  should 
be  tightened  after  pressing  the  blood  out.*  Thus  the  operation  is  rendered 
bloodless.  Nsevi,  being  encapsuled,  may  be  excised  exactly  like  any  solifl 
tumor.  Balmanno  Squire  treats  port- wine  stain  by  systematic  scratchings 
and  cross-scratchings  with  a  hot  cautei-y-needle.  Excision  is  probably  the 
best  treatment  for  aneurism  by  anastomosis. 

Sakcomata. — This  most  interesting  group  of  tumors,  whose  association 
and  nomenclature  are  mainly  due  to  Vii'chow,  includes  the  fihrocellular, 
the  mucous  tumor,  and  the  myeloid  tumor  of  EngHsh  practical  surgery ;  and 
the  group,  on  the  whole,  nearly  corresponds  to  Paget's  recurrent  fibroid. 
Therapeutic  study  and  pathological  study  of  these  tumors  have  been,  un- 
fortunately, very  independent  of  one  another  ;  consequently,  the  varieties 
of  sarcoma  have  two  quite  different  nomenclatures,  one  clinical  and  some- 
what old-fashioned,  the  other  scientific  and  chiefly  German.  The  student 
has  no  right  to  resent  this,  unless  he  thinks  that  science  and  art  should 
always  be  manacled  together,  and  one  never  suffered  to  advance  without 
the  other.  First,  let  us  notice  chief  points  in  the  anatomy  of  sarcomata, 
and  in  doing  so,  employ  a  strict  pathological  classification  (after  Billroth), 
viz.,  into  (1)  granulation  sarcoma ;  (2)  spindle-celled  sarcoma ;  (3)  giant- 
celled  sarcoma  ;  (4)  stellate  sarcoma ;  (5)  alveolar  sarcoma  ;  (6)  pigmented 
sai'coma. 

Granidation  Sarcoma,  Round-celled  Sarcoma  (including  Glioma),  consists 
of  corpuscles  like  those  of  lymph.  Intercellular  substance  is  homogeneous, 
striated,  or  reticulate,  varying  widely  in  amount. 

Spindle-celled  Sarcoma. — CeUs  acutely  spindle-shaped.  Intei-ceUular 
absent  or  scanty,  homogeneous  or  fibrous.  Most  recurrent  sarcomata 
contain  this  tissue  ;  but  every  spindle-ceUed  sarcoma  does  not  recui*. 

Giant-celled  Sarcoma — Myeloid  Tumor. — In  addition  to  the  structural 
elements  of  one  of  the  other  varieties  of  sarcoma,  these  tumors  contain 
large  cells  vdth  many  nuclei,  and  often  with  many  offshoots. 

Net-celled  Sarcoma — IIucous  Sarcoma. — This  is  not  exactly  the  same  thing 
as  myxoma.  Myxomata  are  sarcomata  of  various  kinds,  but  agreeing 
in  having  a  gelatinous  appearance.  Net-celled  sarcoma  contain  steUate 
cells  with  long  processes  and  gelatinous  intercellular  substance. 

Alveolar  Sarcoma. — Very  rare  ;  great  resemblance  to  carcinoma,  but  the 
cells  are  not  so  easily  detached  from  the  meshwork  in  which  they  lie. 
The  cells  are  large,  and  usually  he  each  in  a  space  to  itself,  "  imbedded  in 
a  fibrous,  or  more  rarely  homogeneous,  sHghtly  developed  intercellular 
substance  of  exquisite  areolar  type  "  (Bilh'oth). 

Pigmentary  Sarcoma — 3Ielanotic  Sarcoma — Melanoma. — Pigment  may  oc- 
cur in  any  variety  of  sarcoma.     The  pigment  almost  always  lies  in  the 

*  W.  H.  Brown  of  Leeds. 


246  TUMOES. 

cells.  All  the  cells  mentioned  above  as  occurring  in  the  different  varieties 
of  sarcoma  are  related  genetically  to  corpuscles  of  the  connective  tissues 
(areolar  tissue,  bone,  etc.).  Consequently,  the  cells  of  a  sarcoma  are 
united  by  processes  to  the  intercellular  substance.  In  these  two  peculiari- 
ties, sarcoma  is  distinguished  from  carcinoma,  the  cells  of  which  lie  fi-ee  in 
the  alveoli  of  the  cancer,  and  are  genetically  related,  not  to  connective 
tissue,  but  to  epitheUal  cells. 

Naked-eye  Appearances  of  Sarcomata. — These  do  not  correspond  very 
exactly  to  varieties  in  the  kind  of  cell  found  under  the  microscope.  In 
fact,  several  forms,  e.g.,  spindle-cell,  round-cell,  and  giant-cell,  are  often 
found  in  the  same  tumor.  Some  sarcomata  and  fibrosarcomata  are  firm 
and  tense,  more  or  less  lobed.  On  section,  they  are  seen  to  be  intersected 
with  white  fibrous  bands ;  and,  from  the  pale  yellowish  color  of  the 
section,  an  inexperienced  observer  might  readily  suppose  them  to  be 
chiefly  fat.  They  are  very  succulent  and  juicy  when  freshly  cut.  These 
are  i\ie  fihrocellular  tumors.'  Other  sarcomata,  especially  the  "net-celled," 
are  of  loose,  gelatinous  aj)pearance,  even  so  much  so  as  to  trickle  away  on 
section,  like  the  \'itreous  humor  of  the  eye.  These  are  the  myxomata. 
Others  resemble  lean  "  flesh,"  and,  on  section,  are  seen  to  be  blotched  with 
red,  though  in  the  main  gray,  or  yellow  and  shining.  Such  often  contain 
giant-cells.  Finally,  tumors  which  will  recur,  or  have  already  recurred, 
are  very  often  soft,  and,  with  each  recurrence,  tend  to  get  more  and  more 
encephaloid  or  more  and  more  gelatinous.  Sarcomata  are  Hable  to  cystic, 
calcareous,  osseous,  and  mucous  degenerations. 

Symptoms  of  Sarcomata. — Distinct,  encapsulated  '  tumors.  Usually 
rounded  and  smooth,  often  lobulated.  Consistence  varies  fi'om  great 
firmness  to  the  softness  of  jelly.  When  connected  with  bone,  they  fre- 
quently ossify.  Cicatricial  shrinkage  very  rare  (this  contrasts  with  carci- 
noma). Partial  mucous  softening  and  cystic  degeneration  frequently 
modify  the  consistence  of  a  sarcoma.  Ulceration  occui's  early  in  the  course 
of  sujDerficial  sarcomata,  but  is  not  usually  very  destructive.  The  tumor 
may  then  fungate. 

The  chief  points  for  the  diagnosis  of  sarcoma  are  thus  concisely  given  by 
Billroth  :  "Sarcomata  develop  with  peculiar  frequency  after  j)recedent  local 
irritations,  especially  after  injuries.  Cicatrices,  also,  are  not  unfrequently 
the  seat  of  these  tumors  ;  black  sarcomata  may  come  from  irritated  moles. 
Skin,  muscles,  nerves,  bone,  jDeriosteum,  and,  more  rarely,  glands  (among 
these  the  mamma  most  frequently),  are  the  seats  of  these  tumors.  Sarco- 
mata are  rarest  in  children,  rare  between  ten  and  twenty  years,  most  fre- 
quent in  middle  life,  and  rarer  again  in  old  age.  According  to  my  obser- 
vation, men  and  women  are  affected  with  equal  frequency.  If  these 
tumors  be  not  located  in  or  on  nerve-trunks,  they  are  usually  painless  tiU 

'  See  p.  247. 


TUMORS.  247 

they  break  out.  If  tiie  sarcoma  be  in  the  subcutaneous  cellular  tissue  or 
in  the  breast,  it  may  be  felt  as  an  encapsulated  movable  tumor.  The 
gTowth  is  sometimes  rapid,  sometimes  slow ;  the  consistence  varies,  so  that 
it  can  scarcely  be  used  as  a  point  in  diagnosis." 

Topography  of  Sarcoma. — Glioma  is  connected  with  the  neuroglia  of  one 
or  other  of  the  nervous  parts.  It  occurs  in  the  eyeball,  or  attached  to  one 
of  the  cerebral  nerves,  and  is  peculiarly  a  disease  of  childhood.  Myeloid 
tumors  occur  in  medullary  cavity  of  long  bones,  but  more  frequently  in 
lower  jaw.  When  commencing  inside  a  bone,  they  dilate  it  to  a  mere  shell 
at  the  part  affected.  In  those  of  the  lower  extremity,  an  aneurismal  mur- 
mur may  often  be  heard.  Intraosseous  sarcomata  contain  giant-cells,  and 
are  almost  always  solitary  and  innocent.  But  sarcomata  which  grow  from 
periosteum  are  malignant,  and  generally  more  or  less  ossified  :  sometimes 
they  are  myxomata.  Those  sarcomata  which  originate  in  muscular  inter- 
spaces, in  fasciae  and  in  the  skin,  are  almost  always  spindle-celled  and  re- 
curi-ent,  but  (at  all  events,  in  the  first  place)  not  infectious.  The  typical 
recurrent  fibroid  is  to  be  found  among  these. 

In  glands,  a  mixture  of  adenoma  and  sarcoma  is  more  common  than 
pure  sarcoma.  Cysts  often  form,  and  into  these  sarcomatous  tissue  may 
grow  (proliferous  cysts).  Thus  are  formed  serocystic  sarcomata.  Of  the 
glands,  the  female  breast  and  the  salivary  glands  are  most  liable  to  sarco- 
mata. 

Fihrocellular  Tumors  are  sometimes  myxosarcomata  and  sometimes 
merely  fibromata  of  an  unusually  soft  and  oedematous  nature.  Or  they 
may  be  a  combination  of  both. 

Course  and  Prognosis  of  Sarcomata. — Some  {e.g.,  most  myeloid  tumors) 
are  solitary,  perfectly  innocent ;  recurrence,  when  it  takes  place,  being 
probably  due  to  imperfect  removal.  Others  are  not  le§s  infectious  and 
malignant  than  encephaloid  carcinoma.  1.  Those  which  grow  rapidly  are 
soft,  and  the  softer  the  tumor  the  worse  the  prognosis.  2.  The  more  sim- 
ple and  less  differentiated  the  character  of  the  microscopic  elements  of  a 
sarcoma,  the  more  dangerous  it  is.  Recurrent  fibroids,  with  each  recur- 
rence, are  apt  to  become  softer  in  consistence  and  more  "  embryonic  "  in 
microscopic  structure.  It  is  strikingly  characteristic  of  sarcoma  that  it  in- 
fects the  system  through  the  blood-vessels  and  not  through  the  lymphatics 
(except  in  some  rare  cases  quite  late  in  the  course  of  the  sarcoma).  Con- 
trast this  with  carcinoma.  Di£ferent  sarcomata  present  every  intermedi- 
ate grade  of  infectiousness.  Interval  between  recurrence  very  variable. 
Death  eventually  occurs,  in  malignant  cases,  either  from  the  disease  re- 
curring in  a  part  where  operation  is  impossible,  or  from  infection  (often 
emboHc)  of  internal  organs.  Number  of  secondary  sarcomata  unlimited. 
Their  favorite  internal  sites  are  peritoneum,  pletu*a,  and  limgs. 

Treatment. — Depends  to  a  certain  extent  on  locality  ;  but,  as  a  general 
rule,  prompt  excision  is  indicated.    In  the  case  of  mammary,  subcutaneous, 


248  •  TUMOKS. 

intramuscular,  and  osteal  or  periosteal  sarcoma,  there  need  be  no  hesita- 
tion ;  but  adenosarcomata  of  the  saHvary  glands  in  elderly  people  are 
prone  to  extremely  quick  recurrence.  Excision  must  be  thorough,  and  in- 
clude every  offset.  Caution. — Small  sarcomata  are  occasionally  overlooked 
when  lying  near  larger  ones.  Esmarch  claims  for  pot.  iod.  iu  large  doses 
a  curative  power  over  recui-rent  fibi'oid. 

Lymphoma, — (1)  Idiopathic  disease  of  the  lymphatic  glands,  or  (2)  a 
tumor  resembling  a  mass  of  lymphatic  cells  with  a  stroma  of  adenoid  tissue 
but  not  situated  in  the  site  of  any  normal  lymphatic  gland.  As,  micro- 
scopically, almost  all  affections  of  lymphatic  glands  are  indistinguishable, 
and  as  so-called  "lymphomata"  present  every  gi-ade,  from  innocency  up  to 
intense  malignancy,  it  is  obvious  that  milder  cases  cannot  be  separated 
from  mere  secondary  glandular  inflammations  or  fi-om  scrofula.  Indeed 
lymphomata,  as  a  class,  have  been  termed  "scrofulous  sarcoma."  But 
surgeons  are  generally  agreed  in  setting  apart  fi'om  other  glandular  dis- 
eases, cases  Hke  the  following  :  (1)  One  or  more  glands,  in  the  neck  usually, 
enlarge  and  resist  treatment.  Obstinate  ansemia  comes  on.  Suffocation 
by  mechanical  pressure  may  cause  death  ;  or  the  progressive  anaemia — 
frequently  with  leucocythemia — proves  fatal.  Occasionally  the  disease  is 
arrested  by  antiscrofulous  treatment  or  even  spontaneously.  Various  glands 
in  other  parts  of  the  body  often  enlarge  also.  (2)  Glands  enlarge  quickly 
to  soft  "medullary  tumors,"  the  lymph-corpuscles  simultaneously  infiltrat- 
ing the  neighboring  tissues.  Anaemia  and  marasmus  come  on  and  advance 
rapidly  to  a  fatal  result.  Excision  is  followed  by  recurrence.  Systemic 
infection  may  take  place.  Prognosis  is  almost  hopeless.  Anatoviy  of 
lymphoma. — All  the  cellular  elements  of  the  gland  are  multiplied  and  en- 
larged; "the  structure  of  the  gland  is  gradually  lost  entirely;  the  whole 
organ  becomes  a  mass  of  lymph-ceUs,  although  a  fine  network  is  generally 
XDresei-ved."  "The  blood-vessels  are  preserved  and  their  waUs  greatly 
thickened."  Treatment. — At  first  try  antistrumous  remedies,  cod-hver  oil, 
iron,  etc.  Iodine  injections,  electrolysis,  and  compression  aj)pear  to  suc- 
ceed occasionally,  but  rarely.  Excision  may  be  performed  when  the  glands 
are  distinct  and  are  causing  local  trouble.  BiUroth  treats  mahgnant 
lymphoma  successfully  with  arsenic — Hquor  ai'senicali,  tinct.  ferri,  aa  ^,.  v., 
bis  die.  Increase  by  one  drop  every  second  or  third  day  tOl  symj)toms  of 
jDoisoning  aj)pear.  Then  diminish  by  one  drop  every  second  day.  See 
Allgemeine  medicinische  Central-Zeitung,  May  16,  1877. 

PAPnxosiATA. — ^Include  warts  and  horny  excrescences.  Paj)illomata  are 
foi-med  of  hj^Dcrtrophied  cutaneous  papiUte,  covered  by  hypertrophied 
epidermis.  Warts  usually  show  each  papilla,  with  its  thickenfed  epidermal 
covering,  distinct  to  the  naked  eye.  The  ordinary  wart  is  too  well  known 
to  need  description,  but  there  is  a  disease  described  by  Mr.  Erasmus 
Wilson  as  verruca  conjluens,  in  which  a  considerable  area  of  skin  becomes 
the  seat  of  a  warty  growth.     Syphilitic  and  gonorrhoea!  condylomata  are 


TUMORS.  249 

more  like  hypertrophied  granulation  tissue  than  like  true  papillomata. 
Causes. — Unknown.  Much  more  common  before  thaji  after  puberty.  Ir- 
ritating fluids,  such  as  the  hands  of  the  i:)ost-mortem  clerk  are  exposed  to, 
often  cause  a  warty  state  of  the  skin.  Treatment. — Shave  off  the  non-vascu- 
lar summit  and  apply  some  caustic.  Nitrate  of  silver,  strong  nitric  acid, 
glacial  acetic  acid,  acid  nitrate  of  mercury.  MUder  apphcations  may  suf- 
fice, e.g.,  strong  tinct.  feiTi  perchlor.  For  gonoiThoeal  warts,  try  powdered 
sulphate  of  copper,  and  for  syphilitic,  calomel,  with  oxide  of  zinc.  Dr. 
Verco  has  observed  a  severe  crop  of  common  warts  disappear  rapidly  du- 
ring a  sea-voyage.  Horny  excrescences  in  man  are  epidermal  in  structure 
vdth  a  papillomatous  base.  Treatment. — Shave  off  and  thoroughly  cauterize 
base  or  excise  base.  Some  radical  operation  quite  necessary,  or  they  grow 
again,  and  may  become  starting-point  of  epithelioma. 

Ades-03iata. — Partial  Glandular  Hypertrophy. — Tumors  containing  some 
proportion  of  glandular  structure.  This  is  usually  mixed  with  some  other 
tissue,  and  the  relative  proportions  vary  much.  Thus  are  produced  adeno- 
Jibroma,  adenosarcoma,  etc.  Microscopically,  they  are  characterized  by  the 
pi'esence  of  tissue  resembling  tubular,  and  sometimes  racemose  glands. 
By  great  dilatation  of  the  tubules,  cysts  may  be  formed.  In  shape  the  tu- 
mors are  usually  round  or  oval,  and  lobed  ;  but  their  other  physical  char- 
acteristics depend  greatly  upon  the  kind  of  tissue  which  accompanies  the 
adenomatous — e.g. /em  adenomj-xoma  would  be  very  soft,  an  adenochon- 
droma  usually  very  hard.  Any  innocent,  smooth,  round,  lobed,  and  elas- 
tic tumor  situated  in  the  breast,  or  in  the  jjarotid,  is  very  Hkely  to  be,  at 
all  events  partially,  adenomatous.  Billroth  says  that  he  considers  true 
adenoma  of  the  breast  to  be  veiy  rare,  the  glandular  tissue  found  in  mam- 
mary sarcomata  being  merely  part  of  the  original '  acini  of  the  organ. 
Nasal,  uterine,  and  rectal  iDolypi  are  often  partial  adenomata ;  soHd  or 
semi-sohd  bronchoceles  are  adenomata.  Treatment. — Pedunculated  adeno- 
mata can  be  removed  by  polypus-forceps,  by  ligature,  by  ecraseur,  or  by 
scissors,  or  by  combinations  of  Hgatnre  and  scissors.  See  Polypus  of  Nose, 
of  RECTtni,  and  of  Eak.  For  treatment  of  thyreoid  and  mammary  adeno- 
mata, see  Pkonchocele  and  Breast  respectively.  It  may  be  shortly  stated 
that  excision  is  the  usual  treatment,  but  that  no  tumors  are  so  frequently 
cured  spontaneously,  or  without  operation,  as  adenomata. 

Cystic  Tumors — Cystomata — Cysts. — Definition. — "  A  tumor  formed  by  a 
sac  filled  with  fluid  or  pulp."  Varieties. — The  names  of  cysts  have  been 
given  on  principles  nearly  as  various  as  those  on  which  human  beings 
have  been  named.  Thus  we  have  :  I.  (1)  Simple  and  (2)  compound  cj^sts. 
n.  (1)  Extravasation  ;  (2)  exudation ;  and  (3)  retention  cysts.  UI.  (1) 
Serous;  (2)  synovial;  (3)  mucous;  (4)  blood;  (5)  sebaceous;  (6)  pro- 
liferous cysts.  rV.  Congenital  cysts.  The  four  classifications  being  based 
respectively  on  number,  on  mode  of  origin,  on  contents,  and  on  period  of 
origin.     (Proliferous  cysts  are  those  which  contain  growths  within  them. 


250  TUMORS. 

They  are  practically  identical  with  "  compotiiid  cysts."  All  other  cysts  are 
"  simiDle.")  Causes. — Extravasation  cysts  are  due  to  extravasation  of  blood. 
They  are  usually  traumatic.  See  H^matohia.  Exudation  cysts,  at  least 
such  as  ai-e  ordinarily  regarded  as  tumors,  are  of  unknown  origin,  except- 
such  as  arise  from  local  irritation.  Retention  cysts  are  due  to  obstruction 
of  the  orifice  of  some  gland  causing  dilatation  behind  it.  It  ought  to  be 
noted  that  the  class  exudation  cysts  is  by  Virchow  considered  to  include 
such  serous  dropsies  as  hydrocele,  ganglion,  and  hydrarthrosis ;  while 
"retention  cysts"  include  even  dropsy  of  the  gall-bladder,  dilatation  of 
the  Fallopian  tubes,  and  so  on.  We  shall  now  consider  the  anatomy,  diag- 
nosis, prognosis,  and  treatment  of  each  variety  of  cyst  separately. 

Serous  Cysts. — Seats. — Most  commonly  in  or  near  glands,  kidneys,  thy- 
roid, breast,  sublingual,  etc.  "When  in  the  neck  they  are  called  "hydro- 
cele of  neck."  They  may  occur  almost  anywhere  and  in  any  tissue.  Con- 
tents.— Fluid  usually  thin,  but  sometimes  honey-like,  usually  yellow  and 
clear,  but  may  be  dark  even  to  blackness.  Walls  of  connective  tissue  lined 
v.ith  tesselated  epithehum.  Number,  various.  Growth  is  usually  slow. 
Diagnosis. — Not  difficult  when  the  fluid  is  thin  and  the  cyst  not  tensely 
filled ;  but  a  very  tense  cyst  may  be  mistaken  for  a  sohd  growth.  The 
practised  touch  usually  suffices  to  distinguish  the  fluctuation, of  a  cyst 
from  the  elasticity  of  an  adenoma,  a  fibrocellular,  or  other  soft  soHd 
tumor.  The  latter  are  more  likely  to  be  lobed,  and  possess  various  sjDecial 
characters  described  above.  Abscesses  may  be  recognized  by  the  history, 
and  by  considering  locaHty,  age,  pain,  etc.  It  is  not  often  very  important  to 
make  a  diagnosis  before  punctiu'ing.  Treatment. — Puncture  with  trochar 
and  canula,  followed  by  pressure.  Iodine  injections.  See  Beonchocele. 
Drainage  :  in  large  cysts,  antiseptic  precautions  to  be  taken.  Cauterizing 
interior.  Free  incision.  Excision.  Multij)le  cyst  may  require  excision 
of  a  whole  affected  gland.  When  the  cyst  is  not  complicated  with  some 
recurrent,  solid  gi'owth,  and  when  operations  on  it  are  performed  with  due 
care,  prognosis  is  most  favorable. 

Mucous  Cysts. — Type,  ranula,  q.  v. 

Blood-Cysts — Sanguineous  Cysts. — Are  either  serous  cysts  into  which 
hemorrhage  has  occurred,  or  else  hsematomata.  Treat  on  the  same  prin- 
cijples  as  serous  cysts,  and  hsematocele  of  the  tunica  vaginalis.  Blood- 
cysts  frequently  occur  in  malignant  tumors,  in  which  they  are,  of  course, 
of  quite  secondary  importance. 

Cutaneous  Cysts. — Under  this  head  may  be  considered  sebaceous  con- 
genital cutaneous  cysts. 

Sebaceous  Cysts  are  of  two  kinds,  one  of  which  shows  the  punctiform 
vestige  of  the  orifice  of  the  follicle  by  whose  obstruction  the  cyst  has  been 
produced,  whilst  the  other  does  not.  The  vestige  above  mentioned  is  a 
dark  point  which  can  usually  be  found.  Locality. — Anywhere,  but  espe- 
cially head  and  face,    .  Walls  usually  soft  connective  tissue.     Contents. — 


TUMOES.  251 

White,  pulpy  epidermal  matter,  mixed  with  crystals  of  cholesterine,  often 
offensively  smelling.  Color  occasionally  brownish,  and  consistence  some- 
times very  soft.  Shape  round,  smooth,  often  changeable  by  pressure. 
Growth  slow.  Age  of  first  aj)pearance,  before  middle  age ;  but  the  sur- 
geon is  not  usually  consulted  about  them  at  -first.  They  have  to  be  diag- 
nosed from  chi'onic  abscess  and  other  soft  innocent  tumors.  Note  the 
characters  mentioned  above.  Locality,  history,  absence  of  elasticity,  and 
presence  of  the  black  point  are  important. 

Congenital  Cutaneous  Cysts. — Locality. —1x1  or  near  orbit,  often  deejD- 
seated.  May  extend  through  aperture  in  bone,  even  into  cranial  cavity. 
Walls. very  thin.  Contents  usually  turbid,  oily  fluid.  Size  small  (half  an 
inch).  Diagnosis. — From  n^evus,  lipoma,  and  from  serous  cyst.  Congenital 
cutaneous  (dermoid)  cysts  occur  also  in  other  parts  of  face  and  neck,  but  al- 
ways in  the  lines  of  the  branchial  clefts.  Hence  their  possible  origin  from 
the  accidental  enclosure  of  dermal  tissue  when  these  clefts  closed  (Verneuil. 
See  Wagstaffe,  "Pathological  Transactions,"  1879).  Congenital  dermoid 
cysts  of  the  head  sometimes  perforate  the  cranium,  and  then  may  be  con- 
founded with  meningocele  or  encephalocele.  This  is  not  so  serious  a  mis- 
take as  the  converse.  See  Meningocele.  Treatment  of  the  Cutaneous  Cyst. — 
1.  Dilate  the  black  punctiform  opening  with  a  probe,  and  squeeze  out 
contents.  Eepeatedly  squeeze  out  if  they  reform  till  the  sac  has  time  to 
obliterate  itself.  2.  Cauterize  (to  the  size  of  a  sixpence)  with  potash  or 
strong  nitric  acid.  Afterward  pull  cyst  out  through  the  opening.  3.  In- 
cise skin  over  tumor,  seize  with  forceps,  and  dissect  out.  Operation  easy 
unless  inflammation  has  taken  place. 

Compound  Cysts — Prollfeeous  Cysts. — Definition. — Cystic  tumors  con- 
taining growths.  When  these  growths  are  themselves  cystic,  the  tumor  is 
called  a  cystigerous  cyst.  But  the  growths  are  usually  solid.  Excellent  ex- 
amples of  cystigerous  cysts  are  furnished  by  many  ovarian  tumors. 

Note. — Many  cysts  clustered  together  do  not  in  themselves  constitute 
a  compound,  but  a  multiple  cystic  tumor. 

Anatomy  of  Proliferous  Cysts. — The  solid  intra- cystic  growths  appear 
to  grow  from  one  point  in  the  wall  of  the  containing  cyst.  They  gradually 
fiU  up  the  containing  cyst,  displacing  the  fluid  which  previously  occujDied 
it.  Sometimes  cysts  and  their  contents  cohere  altogether,  so  that  only  the 
appearance  of  a  section  indicates  that  the  tumor  has  ever  been  cystic  at  all. 
The  nature  of  the  intra-cystic  growth  is  usually-  sarcomatous  or  adenosar- 
comatous.  Their  physical  characters  are  as  various  as  possible,  flat  or  ai'- 
borescent,  soft  or  hard,  pale  or  dark  red.  And  they  may  be  themselves 
cystigerous.  Diagnosis. — Locality  almost  always  some  gland — breast, 
th}T.-oid,  etc.  Their  general  characters  resemble  so  closely  those  of  ador 
noma  and  fibroceUular  tumor,  that  unless  palpation  discovers  evidence  of 
fluid  in  some  parts,  and  of  solid  in  others,  diagnosis  will  probably  be  im- 
possible.   Skin  quite  healthy  unless  the  tumor  fungates.    Age— most  com- 


252  ULCEEATION. 

monly  between  thirty  and  forty.  The  chief  practical  indication  is  to  dis- 
tinguish them  fi-om  cancer.  This  is  done  on  the  general  principles  by 
which  other  innocent  tumors  are  thus  distinguished.  Prognosis. — Usually 
favorable.  Prospect  of  recurrence  if  the  whole  tumor  be  not  removed,  or 
if  the  solid  part  of  the  tumor  be  soft  and  sarcomatous.  Treatment. — 
Thorough  excision. 

Caecinomatous  Tumoes. — See  Cancee. 

Ulceration. — One  of  the  "  terminations  "  of  inflammation.  The  de- 
struction of  a  part  by  gradual  molecular  disintegration,  distinguished  from 
gangrene  by  the  fact  that  in  the  latter  j)rocess  the  dead  particles  cohere 
together  after  their  death,  and  from  masses  visible  to  the  naked  eye, 
whereas  in  ulceration  the  disintegrated  tissue  falls  away  in  granules  or 
pieces  of  microscopic  size,  or  else  is  absolutely  liquefied.  The  liquid  in 
which  the  particles  flow  away  is  called  "  discharge  "  or  "  ichor,"  and  varies 
with  the  character  of  the  ulceration.  Chief  Varieties  of  Discharge. — 1.  Thin 
and  serous,  containing  granules,  debins,  and  sometimes  a  little  diffused 
blood  (sanguinolent),  or  a  little  pus  (purulent).  2.  Foul,  quickly  decom- 
posing, sometimes  containing  shreds  of  gangrenous  tissue.  3.  Laudable 
■pxLS,  which  consists  almost  entirely  of  serum  crowded  with  pus-corpuscles, 
which  are  leucocytes  escaped  from  the  blood-vessels.  Its  creamy  appear- 
ance well  known.  Contagious  discharge  may  assume  any  of  the  above  ap- 
pearances. The  first  kind  flows  from  spreading  ulcers,  the  second  from 
still  more  active  ulcerations  (phagedena),  the  third  from  healthy,  healing 
ulcers. 

Classification  or  Ulcees  (Paget's). — I.  (Type)  Simple  or  healthy  ul- 
cer.* '  n.  Varieties  depending  on  constitutional  causes  (eleven)  :  1,  in- 
flammatory ;  *  2,  eczematous  ;  *  3,  cold  ;  4,  senile  ;  (*  5,  strumous ;  *  6, 
scorbutic  ;  *  7,  gouty ;  *  8,  syphilitic — strictly  constitutional ;)  9,  lupous  ; 
*  10,  rodent ;  11,  cancei'ous.  IH,  Varieties  depending  on  local  conditions 
(eight)  :  1,  varicose  ulcer ;  2,  cedematous  ;  *  3,  exuberant ;  4,  hemorrha- 
gic ;  *  5,  neuralgic  or  irritable  ;  *  6,  inflamed  ;  *  7,  chronic  or  callous  ;  *  8, 
phageda?nic  and  sloughing.  It  is  customary  in  describing  an  ulcer  to 
notice  its  (1)  locality,  (2)  shape,  (3)  size,  (4)  base,  (5)  border,  and  (6)  se- 
cretion. 

Simple  or  Healthy  Ulcer. — Arises  from  loss  of  substance  due  to  accident 
or  to  some  pre-existing,  but  now  past,  diseased  condition.  Locality,  num- 
ber, shape,  and  size — very  variable.  Base — covered  with  small  red  granu- 
lations, not  painful  and  not  readily  bleeding,  neither  raised  nor  much 
sunk  below  level  of  surrounding  skin.  Border — outer  circle  of  thin  white 
new  epidermis,  inner  circle  of  still  thinner  (and  therefore)  blue  epidermis. 

'  The  thirteen  varieties  marked  with  an  asterisk  are  the  mosb  important  to  remem- 
ber. The  rest  are,  so  to  speak,  subsidiary  either  to  other  ulcers  or  to  altogether 
special  diseases. 


ULCERATION".  2&3 

Pus,  if  present,  laudable.  Treatment. —  Merely  protective,  e.g.,  simple 
ointment  on  lint,  and  avoidance  of  irritation.  Process  of  Healing. — Identi- 
cal with  that  of  supei-ficial  wound  with  loss  of  substance. 

Infl.\mmatoey  Ulcer. — Locality :  usually  lower  part  of  shin.  Shape, 
iiTegular.  Size  :  usually  less  than  an  inch.  Base  :  without  gi-anulations, 
raw  and  sloughy.  Edges,  abinipt.  Discharge  thin,  acrid,  often  blood- 
tinged.  Surrounding  skin  inflamed,  cedematous.  Causes. —  General 
causes  of  inflammation,  especially  constant  local  irritation,  bad  diet,  old 
age,  and  drink.  Treatment. — Kest,  elevation,  water-dressing,  poultices, 
warm  lead-lotion,  followed  in  twenty-four  hours  by  Martin's  elastic  band- 
age.    Or  the  bandage  may  be  applied  without  any  preparatory  treatment. ' 

EczEHL\T0us  Ulcer. — Resembles  the  last-mentioned  (inflammatory)  in 
character,  but  appears  in  the  middle  of  a  patch  of  eczematous  skin,  in  the 
vesicle  of  which  it  has  often  originated.  Sometimes  its  immediate  cause 
is  a  slight  injury.  Treatment. — Treat  surrounding  eczema,  e.g.,  with  zinc 
ointment.  But  the  sore  itself  must  be  managed  as  an  inflammatory  ulcer. 
Martin's  bandage.  Danger  of  causing  internal  disease  by  curing  eczema- 
tous ulcer  (?). 

Cold  Ulcer. — Resembles  chilblains,  and  occurs  on  fingers  and  toes  of 
people  with  feeble  circulation  and  cold,  congested  extremities,  especially 
young  women  with  deranged  sexual  function.  Aloes,  iron,  warm  gloves, 
thick  boots,  free  exercise  in  open  air.  Dry  lint.  Stimulating  lotions,  e.g., 
zinci  sulph.  (gr.  iij.-  3  j.). 

Senile  Ulcers. — Kind  of  inflammatory  vlcer,  occurring  in  withered  old 
people.  Nearly  related  to  senile  gangrene,  with  which  it  may  be  combined. 
Vide  Senile  Gaj^grene.     Locally  :  resin  ointment  and  Peruvian  balsam. 

Struimous  Ulcers. — Locality :  neck,  groin,  knee,  ankle,  elbow,  wrist, 
and  sometimes  elsewhere.  Often  multiple.  Shape :  oval  when  single. 
Size  :  small  singly,  but  often  vei-y  large  by  coalescence  of  several.  Edges 
undermined.  Base  soft,  granulations  large,  readily  bleeding,  cedematous. 
Discharge,  thin,  greenish  pus.  Treatment. — That  of  scrofula.  Locally : 
stimulant.  Ung.  hydrarg.  oxid.  rubx'i,  unguentum  plumbi,  lotio  iodi 
(tinct.  iodi  c.  aquse),  on  strips  of  lint.     Iodoform. 

Scorbutic  Ulcers  occur  in  the  course  of  scurvy,  and  are  covered  with 
crusts  of  the  characteristic  blood-clot  deposit  of  scurvy.  Indolent  and 
livid.      Vide  Scurvy. 

Gouty  Ulcers. — Superficial,  indolent,  occur  in  gouty  parts,  especially 
over  gouty  deposits.  Discharge  itself  leaves  a  chalky  precipitate.  Treat- 
ment.— Water  dressing.  In  absence  of  inflammation,  sol.  argent,  nit.  (gr. 
v.,  aquse,  3  j. )  may  be  used.  « 

SypmuTic  Ulcers. — Primary  syphilitic  ulcers  {i.e.,  chancres)  may  occur 
on  lips,  hands,  etc.     For  their  characteristics  vide  Syphilis.     Secondary 

'  The  case  must  then  be  carefully  watched,  for  there  is  a  danger  of  erysipelas. 
Iodoform  is  a  valuable  application  to  any  ulcer  not  actually  inflamed. 


254 


ULCERATION". 


eruptions  rarely  ulcerate  :  they  are  known  by  their  concomitants.  Terti- 
ary are  almost  all  the  cutaneous  ulcers  named  syphilitic.  Commence  in 
two  ways  :  1,  cutaneously  (usually  in  rupia)  ;  2,  subcutaneously  (a  gumma 
ulcerating  outward) .  The  two  varieties  ag-ree  in  occurring  anywhere,  in 
having  abinipt  edges,  in  often  being  surrounded  by  a  red  areola,  in  being 
associated  with  a  syphilitic  history  (perhaps  merely  congenital),  and  in 
benefiting  by  antisyphilitic  treatment,  especially  iodide  of  potassium  ;  but 
they  differ  considerably.  1.  That  ivhich  begins  superficially  has  for  its  fa- 
vorite locality  the  trunk.  Shape  :  annular,  crescentic,  or  circular.  Size  : 
various.  Base  :  level,  crimson.  Granulations :  small  or  absent.  Dis- 
charge concretes  into  scabs,  often  rupial  in  character.  Not  generally 
simultaneous  with  any  other  syphilitic  manifestation.  One  of  the  earliest 
tertiary  manifestations.  2.  Deep  tertiar}'  sj^ohilitic  ulcers  are  caused  by  a 
gumma  finding  its  way  outward  through  iilceration  of  the  skin.  Locahty  : 
anywhere — usually  limbs  near  the  large  joints.  Shape  :  rounded.  Size  : 
about  an  inch  ;  usually  multiple.  JEdges  :  abrupt.  Base  :  excavated,  often 
covered  with  "  gummy  deposit "  sloughed.  They  have  to  be  diagnosed 
from  strumous  ulcers.  The  latter  have  a  pink  suiTOunding  area,  the  for- 
mer usually  a  dusky  red  one.  Treatment  of  tertiary  sj^^hilitic  ulcer. — 
Locally  :  stimulant  mercurial  ointments,  e.g.,  ung.  hyd.  oxid.  rubri,  or 
tmg.  hyd.  nitric-oxid.  or  lotio  nigra  ;  iodide  of  potassium,  gr.  v.-x.  ter  die. 
Small  doses  of  liq.  hydrarg.  perchlor.,  etc.      Vide  Syphilis. 

Lupous  Ulcers,  Kodent  Ulceks,  and  Ulceeating  Epithelioma  may  be 
usefully  contrasted  as  follows : 


Lupous  Ulcer. 


Locality :  most  frequent- 
ly face,  especially  tip  or 
aliB  of  nose,  upper  lip, 
cheek.  Female  external 
genitals.  Anterior,  infe- 
rior part  of  nasal  septum. 
Pharynx. 

Borders :  abrupt,  irreg- 
ular, sometimes  sUghVy 
elevated  or  thickened, 
very  rarely  undermined. 

Base  :  more  or  less  level. 
Granulations  nearly  ab- 
sent, or  else  coarse  and 
dusky. 


Often  scabbed  over. 

Preceded  by  pink,  firm, 
flattened  tubercles. 


Eodent  TJlcer. 


Most  frequently,  cheeks, 
eyelids,  upper  lip,  nose, 
scalp.  Also  vulva,  vagina, 
areola  of  breast,  near  anus, 
etc. 


Abrupt ;  perhaps  with  low 
tubercles  near,  never  under- 
mined, not  everted;  tough, 
hard. 

Smooth,  dull  reddish  yel- 
low, looking  half-dry  and 
glossy,  void  of  granulations. 
Base  feels  tough  and  hard, 
as  if  bounded  by  a  layer  of 
indurated  tissue  half  a  line 
to  a  line  in  thickness. 

Very  little  discharge  in- 
deed. 

Commences  in  some  tu- 
bercular or  scaly  spot  of 
long  duration. 


TJlceratihg  Epithelioma  of  the 
Skin. 


Great  majority  occur  on 
lower  lip,  lower  ej'elid. 
Other  places  where  skin  and 
mucous  membrane  join,  e.g., 
anus,  vulva,  prepuce.  Also 
scrotum,  back  of  hand,  and 
any  other  part  of  skin. 

Generally  raised,  everted, 
hard,  nodular,  warty. 


Uneven,  concave,  hard, 
nodular,  warty,  fissured. 
Coarse  granulations.  Base 
and  surrounding  parts  hard, 
thickened  and  infiltrated 
with  cancer. 

Often  scabbed  over  when 
small. 

Begins  in  many  ways — 
tubercles,  warts,  ulcers,  fis- 
sures, cicatrices,  etc. 


ULCEEATION.  255 

Tiie  course  of  each  is  destructive  to  every  neighboring  tissue.  Progress 
usually  slow,  always  sure.  Lupus  is  often  associated  with  scrofulous  consti- 
tution. Eodent  ulcer  more  frequently  coexists  with  perfect  general  health. 
The  same  may  be  said  of  ej)ithelioma,  but  epithehoma  is,  of  all  the  three, 
most  usually  painful  and  productive  of  cachexia.  Epithehoma  alone  in- 
volves, secondarily,  the  glands ;  and  the  infection  may  spread  to  the  en- 
tu'e  system.  This  is  what  constitutes  its  truly  cancerous  nature.  Rodent 
ulcer  would  only  be  described  as  semi-maHgnant.  The  last  sentence  is 
meant  to  be  vmderstood  in  a  purely  cHnical  sense.  Pathologically,  "  ro- 
dent ulcer  "  is  as  truly  carcinomatous  as  ej^ithehoma,  according  to  Bill- 
roth.' Lupus  is  pathologically  allied  to  tubercle,  quod  vide.  Treatment. — 
Lupus  :  use  Volkmann's  erosion  treatment,  i.e.,  scrape  the  disease  away 
with  some  spoon-shaped  instrument.  Antiscrofulous  remedies,  cod-liver 
oil,  etc.  Eodent  idcer  :  thorough  destruction  with  cauteiw  or  caustic. 
Benzoliue  cautery.  Among  caustics,  arsenic  is  very  convenient,  but  un- 
safe except  in  case  of  very  small  sores ;  nitric  acid  acts  rather  superficially  ; 
Vienna  paste  and  chloride  of  zinc  paste  are  the  best  deep  caustics.  For 
treatment  of  cancerous  ulcers,  vide  Cakcer.  Esmarch  and  Billroth  have 
had  encouraging  results  fi'om  large  doses  of  arsenic  internally  in  cancer 
cases.  Reasoning  by  analogy,  the  power  of  ai-senic  over  psoriasis  (super- 
ficial epithehal  hypertrophy)  suggests  a  possible  power  over  cancer  (inter- 
stitial epithelial  hypertrophy).  Lupus  often  returns.  Rodent  ulcer,  if 
completely -extu-pated,  rarely  returns.  Prognosis  after  operation  for  epithe- 
lioma depends  on  whether  or  not  time  has  been  given  for  glandular  infection. 

For  other  cancerous  \ilcers  see  Cancee. 

Section  HE. — Varieties  of  Ulcer  depending  on  Local  Conditions.— They 
do  not  need  a  full  description,  as  each  term  owes  its  existence  to  some 
single  imjjortant  condition  grafted  on  one  or  other  of  the  ulcers  already 
described.  The  nature  of  this  characteristic,  together  with  causation, 
diagnosis,  and  treatment,  have  to  be  considered. 

Varicose  Ulcer.— Its  characteristic  is,  that  it  owes  either  its  origin  or 
continuance  mainly  to  the  existence  of  varicose  veins.  Two  direct  modes 
of  origin  :  (1)  in  suppuration  over  a  thickened  varix  ;  (2)  in  eczema  caused 
by  obstructed  cutaneous  circulation.  Form  assumed  by  varicose  ulcer  is 
that  of  inflammatory,  of  eczematous,  or  of  chronic  ulcer,  q.v.  The  treat- 
ment is  acording  to  the  particular  natui'e  of  the  individual  ulcers.  But, 
always,  either  rest  and  elevation  or  else  pressure.  Martin's  bandage. .  Give 
iron  internally. 

The  terms  cedematous,  exuberant,  and  hemorrhagic  refer  to'  the  state  of 
an  ulcer's  granulations,  and  almost  exj^lain  themselves.  (Edematous  gran- 
ulations are  usually  connected  with  diseased  bone.     Exuberant  granula- 


'  Paget  inclines  to  the  same  view.     But  Thin  says  that  rodent  ulcer  is  an  adenoma 
of  the  sweat-glands.     Pathological  Transactions,  1879. 


256  URETHRA,    STRICTURE    OF. 

tions  have  to  be  diagnosed,  by  their  softness,  from  cancer.  An  ulcer  may 
be  hemorrhagic  from  (1)  vicarious  menstruation,  (2)  small  and  diseased 
varicose  veins,  (3)  scui-vy,  (4)  hemorrhagic  diathesis,  (5)  phagedsena,  (6) 
malignant  disease,  (7)  mere  accidental  injury  or  congestion.  In  the  case 
of  osdematous  and  hemorrhagic  ulcers  it  is  necessary  to  treat  the  cause. 
Pressure  and  caustics  will  destroy  oedematous  or  exuberant  granulations. 
The  popular  name  for  the  latter  is  "  proud  flesh." 

Neuralgic  oe  Ireit.\ble  Ulceks. — Usually  more  or  less  inflamed,  or  sub- 
ject to  constant  irritation,  e.g.,  fissures  round  anus  or  mouth.  If  soothing 
ointments,  cleanliness,  and  local  rest  wiU  not  cure  them,  a  touch  of  solid 
caustic  may.  CarboHc  lotion  is  an  excellent  local  sedative.  See  Anus, 
Fissure  of. 

Inflamed  Ulcer. — Kecognized  by  the  presence  of  the  four  classical 
signs  of  inflammation  in  the  borders  of  the  rJcer.  Surface  of  ulcer  also 
changes,  becomes  "  angry -looking,"  dusky,  swollen,  perhaps  sloughy. 
Treatment. — Kest,  elevation,  weak  carbolic  or  lead  lotion.  Purgatives. 
Occasionally,  poultices  are  convenient. 

Chronic,  Indolent,  or  C.UiLOus  Ulcers. — Seat :  almost  always  the  leg. 
Border  thick,  hardened,  brawny,  abrupt,  covered  with  thick,  old,  opaque 
epidermis,  and  devoid  of  any  delicate,  new  ej)idermis  such  as  suiTOuiads  a 
healing  ulcer.  Base,  sunken,  pale,  or  dusky,  without  granulations,  usually 
insensitive.  Secretion,  thin,  offensive.  Various  kinds  of  ulcers  attain  this 
condition  through  neglect  or  continued  irritation,  combined  with  feeble 
local  circulation.  Treatment. — Above  all,  pressure.  Martin's  bandage. 
Baynton's  dressing  (strapjjiag  with  adhesive  plaster).  Covering  ulcer  and 
its  borders  with  a  blister.  See  Syme's  "  Essays."  Very  few  cases  of  un- 
complicated chronic  ulcer  can  now  justify  amputation. 

Phagedenic  and  Sloughing  Ulcer. — See  Gangrene  and  Svprnxis. 

Urethra,  Stricture  of, — Glasdfication  :  (1)  spasmodic,  (2)  inflamma- 
tory, (3)  organic.  Organic  are — A.  Of  neoplastic  origin  :  (1)  annular,  (2) 
indurated  annular,  (3)  diffuse  or  tortuous,  (-4)  bridle,  (5)  caruncle,  (6) 
traumatic ;  B.  Of  heteroplastic  origin :  epithelioma,  etc. 

Causes. — Of  Spasmodic  Stricture :  almost  always  an  organic  predis- 
posing cause,  situated  within  the  urethra.  Dyspepsia  or  gouty  diathesis 
with  consequent  acid  state  of  the  urine.  Irritating  diuretics,  e.g.,  can- 
tharides.  Some  foreign  body,  e.g.,  passage  of  a  bougie  or  of  a  minute 
calculus.  Some  disorder  of  the  central  nervous  system.  Of  Infianimatory 
Stricture:  exercise,  excitement,  alcoholic  or  other  excess  during  course 
of  a  gonorrhoea.  Of  Organic  Stricture:  the  great  majority  arise  from 
gonorrhoea,  especially  chronic  gonorrhoea  or  gleet.  Some  follow  non- 
specific urethi-itis.  Vide  causes  of  urethritis.  Traumatic  strictures  follow 
rupture  of  the  m'ethra.  Hot  climates.  Abuse  of  alcohoUc  drinks,  espe- 
cially malt  liquors.  Neglect  of  proper  treatment  in  gonorrhoea.  Causti«s. 
Sj^hilitic  ulceration  of  meatus. 


URETHRA,    STRICTURE    OF.  257 

Position. — Spasmodic  stricture  occurs  in  various  parts  of  the  urethra. 
Inflammatory  stricture  is  due  to  acute  inflammation  of  the  prostatic  part. 
Of  organic  strictures,  two-thirds  are  in  the  bulbous  part  of  the  urethra,  i.e., 
in  the  posterior  inch  of  the  spongy  part  (Thompson).  This  is  denied  by- 
Otis,  who  says  that  strictures  are  most  common  in  the  penile  part  of  the 
urethra.  For  confirmatory  observations,  seeLockwood,  "St.  Bartholomew's 
Hospital  Reports,"  1879. 

Signs. — EarHest  symptom  is  usually  a  slight  gleet  (almost  all  obsti- 
nate gleets  are  said  to  be  caused  by  stricture).  Sometimes  retention  is  the 
first  sign  of  all.  Altered  size  and  shape  of  stream — small,  twisted,  spirt- 
ing, forked,  or  even  divided.  A  few  drops  of  urine  trickle  away  after 
micturition  has  apparently  been  completed.  Commencement  of  the  act  of 
urination  difficvdt  and  slow,  act  itself  prolonged.  Advanced  Symiitoms. — 
Constant  desire  to  make  water.  Night's  rest  broken.  Straining.  Sense 
of  heat,  soreness,  and  smarting  about  neck  of  bladdei",  "  greatly  aggravated 
by  an  excess  of  acid  in  the  urine,  by  cold,  or  imprudence  of  any  kind  tell- 
ing on  the  parts."  Pain  in  pubic  region,  in  perinseum,  back,  and  loins. 
Pain  during  coition.  Semen  may  recoil  back  into  bladder.  In  some  stric- 
ture cases  a  discharge  like  that  of  gonorrhoea  may  foUw  sexual  inter- 
course. Anus  shows  efi'ects  of  straining — prolapsus,  and  hemorrhoids. 
In  a  few  cases,  almost  the  only  marked  symptom  is  the  liability  to  attacks 
of  retention. 

Urine  tends  to  become  alkaline  and  ammoniacal, 
C0H^N,  +  H,0=C0,  +  2  NH3 
urea  +  water  =r carbonic  acid  +  ammonia,  is  the  reaction  which  represents 
transformation  of  urea  into  carbonate  of  ammonia.  This  ammonia  irritates 
the  bladdei',  causing  cystitis.  The  urine  contains  also  triple  phosphates  in 
abundance,  as  well  as  pus  and  mucus,  omng  to  the  cystitis.  Occasional 
hsematuria,  from  rupture  of  vessels  near  stricture  during  erection  of  penis. 

Com2)lications. — 1.  Dilatation  of  urinai-y  passages  and  oi-gans  posterior. 
to  stricture — prostatic  part  of  urethra,  bladder,  ureters,  kidneys.  2. 
Atony  and  absoi-ption  of  same  structures  ;  kidney  may  suffer  great  atrophy 
of  its  substance.  3.  Inflammations  and  suppurations  of  the  same  parts,, 
especially  of  bladder  and  kidneys.  4,  Incontinence  of  urine.  5.  Rupture 
of  the  urethra  or  bladder,  and  extravasation  of  urine.  6.  Chronic  abscess 
and  fistula.  7.  Constitutional  effects.  For  most  of  the  above  complica- 
tions, see  notices  elsewhere,  e.g..  Bladder,  Dise.\ses  op.  Kidney,  Urine,  etc. 

Constitutional  Ejects.— lioss  of  strength.  Impaired  digestion.  Thin- 
ness. Careworn  look.  Irritability.  Despondency.  Pains  in  back  and 
loins.  Feverishness  of  intermittent  character.  Urethral  fever  may  be  ex- 
cited by  the  passage  of  a  bougie,  especially  if  the  instrument  be  compara- 
tively large.  When  there  is  organic  kidney  disease,  catheterism  alinost  al- 
ways causes  severe  rigors.  Then  death  may  also  ensue  suddenly,  perhaps 
from  poisoning  by  urea. 
17 


258  URETHRA,  Stricture  of. 

Diagnosis  is  usually  settled  by  passing  instruments.  History  of  case 
may  help  to  demonstrate  natm-e  and  cause  of  the  stricture.  Act  of  mictu- 
rition should  be  observed. 

Prognosis. — Very  good  if  stricture  be  treated  early.  Serious,  if  neglect 
has  allowed  kidney  disease  to  supervene. 

Treatment. — The  immediate  treatment  of  strictures  (whether  inflam- 
matory, spasmodic,  or  organic)  in  which  there  is  retention  of  urine  will  be 
considered  under  the  head  Ubine,  Retention  of.  Treatment  of  strictures 
in  which  there  is  no  urgent  retention.  Varieties  may  be  classed  as  fol- 
lows: (1)  dilatation,  (2)  rupture,  (3)  urethrotomy.  These  three  classes 
include  at  least  eight  methods,  viz. :  (1)  intermittent  dilatation,  (2)  con- 
tinuous dilatation,  (3)  vital  dilatation,  (4)  rupture,  (5)  dilatation  from 
behind — Jordan's  operation,  (6)  internal  urethrotomy,  (7)  external  vu-e- 
throtomy,  (8)  perineal  section.'  1.  Dilatation. — Instruments  :  silver,  gum- 
elastic  (Enghsh),  or  French  catheters  or  bougies.  The  soft  French  in- 
struments are  preferred  to  silver  ones  by  the  majority  of  people  accustomed 
to  both.  Sii'  Henry  Thompson  strongly  recommends  them.  The  English 
gum-elastic  has  the  advantage  that  it  can  be  moulded  to  any  cui've  in  warm 
water,  and  stiifened  in  the  new  curve  by  plunging  it  into  cold  water. 
Silver  catheters  permit  their  points  to  be  directed  with  greater  precision 
than  soft  ones.  The  advantage  of  using  a  catheter  instead  of  a  bougie,  is 
only  that  the  former  instrument,  by  giving  passage  to  urine,  tells  you 
when  it  has  entered  the  bladder.  French  instruments  usually  taper  near 
the  end,  but  have  the  end  itself  nobbed  to  prevent  catching  in  the  urethral 
Jacunse.  Hence  the  name  "  bougie  d,  boule."  The  French  sizes  No.  3  to 
No.  21  coiTespoud  nearly  to  our  No.  1  to  No.  12  :  the  number  of  each  size 
of  the  former  scale  representing  the  number  of  millimetres  in  its  circum- 
ference. Catgut  and  whalebone  bougies  ai-e  also  used  for  very  narrow 
stiictures. 

Eules  for  Ordinary  Catheterism. — 1.  Patient  may  stand  upright  with 
his  back  against  the  wall ;  but  as  he  may  faint,  it  is  safer  for  him  to  lie 
down  on  his  back.  2.  Stand  on  patient's  right  if  he  is  lying  do'OTi.  Sit 
in  front  of  him  if  he  is  upright.  In  difficvdt  cases  bring  the  patient  to  the 
foot  of  the  bed,  and  stand  between  his  legs.  3.  See  that  your  catheter  is 
clean  and  not  blocked  up.  4  Warm  it  slightly.  5.  Oil  it  well.  6.  Steady 
the  penis  with  your  left  finger  and  thumb,  and,  holding  the  instrument 
lightly  between  the  thumb  and  two  fingers  of  your  right  hand,  pass  its 
point  five  inches  down  the  urethra,  that  is  as  far  as  it  will  easily  go  while 
the  instrument  is  in  its  present  position  {that  is  to  say,  with  its  handle 
parallel  to  the  patient's  left  groin).  .  7.  Bring  the  handle  up  to  the  middle 
line  of  the  abdomen,  keeping  the  point  of  the  catheter  well  down  the  ui-e- 


'  To  these  should  be  added   dilatation  by  Wakley's  tubes,  which  glide  one  over 
the  other,  and  the  smallest  over  a  small  silver  catheter. 


4 

I 


URETHRA,    STRICTURE    OF.  259 

thra.  8.  Liglitly  depress  the  handle,  at  the  same  time  pushing  the  point 
onward  round  the  sub-pubic  curve  into  the  bladder,  employing  only  the 
slightest  degree  of  force  with  the  lightest  hand  possible.  By  "  depress 
the  handle  "  is  meant  "  bring  it  downward,  from  the  linea  alba  toward  the 
interval  between  the  thighs."  When  in  the  bladder,  the  catheter  should 
be  parallel  with  the  thighs,  or  nearly  so.  Difficulties  :  (1)  point  may  en- 
tangle in  lacunse  in  roof  of  urethra,  or  in  a  false  passage  ;  (2)  or  may  be 
obstructed  by  the  anterior  layer  of  the  triangular  ligament,  through  which 
the  urethra  passes  about  six  inches  from  the  meatus  ;  (3)  or  by  spasm  ;  (4) 
or  by  an  elevation  near  prostate  or  neck  of  bladder.  At  first  keep  the  point 
on  the  floor  of  the  urethra.  Always  be  patient  and  gentle.  Force  can  do 
no  good,  and  may  cause  much  harm,  especially  false  passages,  hemor- 
rhage, and  pain.  Gum-elastic  catheter :  be  very  careful  to  preserve  its 
curve.  When  you  have  got  the  point  well  down  the  urethra,  depress  the 
handle  rather  suddenly,  but  still  with  a  light  hand.  French  soft  instru- 
ments :  simply  push  them  gently  on  into  the  bladder.  Indications  for 
treatment  of  stricture  :  (1)  to  restore  normal  size  of  urethra  (or  to  dilate 
as  much  as  is  consistent  with  safety  and  comfort)  ;  (2)  to  maintain  the 
ground  gained.  At  the  first  examination  of  a  case  of  supposed  stricture — 
1.  Pass,  or  try  to  pass,  a  medium-sized  instrument.  If  it  passes  very 
easily,  try  a  larger  and  a  larger,  till  you  find  the  largest  which  passes  with- 
out much  pain.  Note  the  size  and  position  of  the  stricture.  2.  If  it  will 
not  pass,  let  the  patient  make  water,  if  he  can.  The  size  of  the  stream 
will  usually  be  a  little  larger  than  the  diameter  of  the  stricture.  3.  If  he 
cannot  make  any  stream  of  water,  carefully  examine  hypogastrium,  to  see 
if  bladder  be  distended.  A  finger  in  the  rectum  to  palpate  base  of  blad- 
der may  assist  in  this  examination.  4.  If  you  have  seen  a  stream  of  water, 
take  an  instrument  a  httle  smaller  than  that  stream,  and  try  to  pass  it.  5. 
But  if  there  is  no  stream  of  urine,  or  if  the  instrument  advised  in  last 
paragraph  (4)  have  failed,  try  the  smallest  soft  French  catheter  you  pos- 
sess. 6.  If  this  fails,  try  your  finest  bougie  or  catgut  or  Thompson's 
probe-pointed  catheter,  or  Maissonneuve's  conducting  bougie  (if  you  pos- 
sess them).  Each  instrument  should  have  a  fair  and  patient  trial.  Use 
plenty  of  good  sweet  oil.  Sir  H.  Thompson  directs  it  to  be  injected  into 
the  urethra.  Another  plan  is  to  inject  it  in  steadily  at  the  very  same 
time  that  you  are  gently  pushing  on  your  fine  bougie.  The  stream  of  oil, 
entering  the  strictm-e,  may  carry  the  point  of  the  bougie  with  it.  7.  If 
the  stricture  resist  all  this,  put  the  patient  to  bed,  and  if  there  is  no  im- 
mediate retention,  reserve  him  to  be  treated  as  a  difficult  case.  In  the 
meantime,  tincture  of  opium,  hot  baths,  and  rest  in  bed  may  bring  his 
stricture  to  a  state  of  easy  permeability. 

Dilatation,  according  to  the  ordinary  plan,  is  thus  managed.  An  instru- 
ment as  lai'ge  as  the  patient  can  comfortabty  endure  is  passed  the  first 
day.     Then,  at  intei-vals  of  about  two  days,  more  or  less  according  to  the 


260  URETHRA,    STRICTURE   OF. 

patient's  irrethral  sensibility,  a  larger  and  a  larger  size  are  passed,  till  No. 
14:  (English)  is  reached.  Modern  opinion  is  opposed  to  resting  content 
•with  No.  12.  If  any  attempt  is  made  to  hurry  the  steps  of  this  treatment, 
the  severest  rigors  and  urethral  fever  may  result.  Some  cases  show  sim- 
ilar serious  symptoms  if  the  surgeon  tries  to  dilate  beyond  even  No.  7  or  8. 
Such  cases  often  get  on  very  well  with  that  calibre  of  urethi-a,  and  require 
no  further  treatment.  Each  instrument  should  be  taken  out  as  soon  as  it 
is  passed.  After  ten  minutes'  horizontal  rest,  the  patient  may  go  about 
his  business  again,  provided  no  unpleasant  symptoms  ensue. 

Continuous  Dilatation. — The  instrument  is  not  withdrawn  for  forty- 
eight  hours,  and  then  only  to  have  a  larger  size  substituted  for  it.  This  is 
an  especially  good  plan  (a)  when  the  instrument  has  been  introduced  with 
difficulty ;  (6)  when  false  passages  exist ;  (c)  if  ordinary  dilatation  is  in- 
effective ;  {d)  if  each  introduction  of  the  instrument  induces  pain  or  rigors. 
Of  course  the  bed  must  be  kept  during  the  treatment  (i.e.,  for  a  week  or 
two).  The  catheter  or  bougie,  when  in,  can  be  fixed  by  tapes  or  strap- 
ping [vide  works  on  bandaging,  etc.),  or  by  tying  it  with  thread  to  the 
hair  of  the  pubes,  a  dii-ection  which  some  critic  of  Smith's  and  Walsham's 
operative  surgery  has  termed  unpractical.  Practical  or  unpractical,  I  have 
myself  constantly  practised  it.  A  cradle  keeps  the  bed-clothes  off  the  hips, 
etc.  Liq.  opii  setl.  iTl,  xx.,  or  moii^hia  suppositories  will  relieve  severe 
pain.  Some  patients  cannot  endure  the  treatment  at  all.  Orchitis  is  a 
possible  comjjUcation.  Diarrhoea  may  require  chalk  mixture.  Hemor- 
rhage may  occur.     Slight  purulent  discharge  accompanies  the  treatment. 

"  Vital"  Dilatation.^ — When  instrument  will  not  pass  through  stricture, 
and  there  is  yet  no  retention,  pass  a  bougie  down  to  stricture  and  leave  it. 
Perhaps  in  a  day  or  two  it  will  pass. 

Rxiptiire  by  Holt's  Dilators. — Mr.  Holt  passes  an  instrument  consisting 
of  two  parallel  blades,  and  then  forcibly  driving  a  tube  down  between 
them,  ruptures  the  stricture.  Give  ether.  Use  sufficient  force.  Pass  a 
No,  10  catheter  immediately.  Remove  it  at  once,  and  pass  it  again  at 
intervals  of  two  days  in  first  week,  then  once  a  week,  then  once  a  fort- 
night, lastly  once  a  month.  This  plan  has  a  great  deal  in  its  favor.  See 
IVIr.  Holt's  book. 

Dilatation  from  Behind. — In  certain  cases,  impermeable  from  the  front, 
Mr.  Furneaux  Jordan  has  plunged  a  bistoury  into  the  membranous  part 
of  the  urethra,  from  the  rectum,  adjacent  to  which  the  membranous  uretlira 
lies.  This  is  done  by  placing  the  patient  in  the  lithotomy  position,  feeling 
for  the  anterior  border  of  the  prostate,  and  cutting  exactly  in  the  median 
hne.  Then  a  fine  bougie  is  insinuated  from  behind  forward,  through  the 
wound. 

Internal  Urethrotomy. — Various  forms  of  urethrotome.     Some  cut  from 

'  Dupuytren,  LeQons  Orales. 


^  URETHRA,    STRUCTURE    OF.  261 

behind  forward,  others  from  before  backward,  in  almost  all  cases  with  a 
guide  previously  passed  through  strictiu'e.  Division  fi'om  behind  forward 
preferred.  Suitable  cases  are  those  strictures  which  either  cannot  be 
dilated  beyond  a  small  calibre,  or  which  rapidly  recontract  after  dilatation. 
Operaiion  (with  Civiale's  urethrotome) :  Ascertain  position  of  strictui'e  by 
means  of  bulb  at  end  of  instrument.  Pass  the  urethrotome  so  far  down  the 
urethi'a  that  when  the  blade  is  projected  the  incision  shaU  commence 
about  ^  inch  beyond  the  stricture.  Ptdl  out  the  instrument,  incising  the 
urethra  for  about  1^  inch  altogether.  There  is  no  danger  in  a  long  incision, 
but  real  danger  in  incising  very  deeply.  Proper  dej^th  about  ^  inch.  As 
a  rule,  pass  no  instrument  for  forty-eight  hours.  Then  pass  a  sound  at 
intervals,  which  should  gradually  increase,  commencing  at  every  other  day. 
Always  press  its  curve  well  down  into  site  of  incision.  Internal  urethrot- 
omy is  relatively  best,  and  absolutely  excellent  in  the  penile  portion  of 
the  urethra.     Mortality,  10  in  1,192  (Teevan). 

External  Urethrotomy. ^SniiahYe  cases  are  those  in  which  "large,  nume- 
rous, or  obstinate  perineal  fistulae  coexist  with  old  or  obstinate  strictui'es. 
When  other  treatment  has  failed,  and  the  fistulae  refuse  to  heal,  even 
although  the  patient  has  withdrawn  for  some  weeks  his  vodne  entu'ely  by 
catheter,  no  proceeding  perhaps  offers  so  good  a  cftince  of  cure  as  this. 
It  is  for  such  cases  I  reserve  it  now."'  Operation. — Pass  Syme's  staff. 
Lithotomy  position.  Best  hght  obtainable.  Operator  sits.  Incise  in  line 
of  raphe,  two  inches.  Feel  for  staff  with  left  forefinger.  Take  staff  in  left 
hand,  and  straight  bistouiy  in  right.  With  right  hand  supine,  cut  through 
stricture  along  groove  of  staff  from  behind  forward.  Withdraw  staff  one- 
fourth  inch,  and  extend  incision  that  distance  further  forward.  Shoulder 
of  staff  will  now  easily  pass  on  through  site  of  divided  stricture  if  the  division 
has  been  thorough.  Thompson  passes  a  concave,  curved  director  through 
the  wound  and  toward  the  bladder,  with  the  aid  of  which  a  catheter  (not 
smaller  than  No.  10)  is  afterward  guided  into  the  bladder.  If  catheter  is 
obstructed  on  its  passage,  strictiore  requires  more  complete  di-sdsion,  which 
should  be  done  there  and  then.  Morphia  suppository.  India-rubber  tub- 
ing to  catheter.  Withdi*aw  catheter  after  forty-eight  hours.  Pass  No,  12 
bougie  at  intervals,  first  of  four  days,  then  one  week,  then  a  fortnight,  and 
so  on.  If  any  diflSculty  in  passing  this  be  experienced  before  wound  heals, 
pass  a  grooved  staff,  and,  with  a  tenotomy  knife  in  the  wound,  divide  the 
obstruction. 

Rules  for  Managing,  a  Stricture  Impermeable  to  Ordinary  Means. — It  is 
assumed  that  there  is  no  urgent  retention.  1.  Rest  in  bed  without  instru- 
mental disturbance  for  three  days  or  more.  2.  Low  diet,  purgative,  alkaUne 
medicines,  demulcent  diinks.  3.  Plenty  of  bed-clothing.  4.  Opium,  twenty 
drops  of  tincture  ;  and  5,  hot  bath,  100°,  rapid  drying  with  towel,  half  an 

'  Thompson  on  Stricture,  p  341, 


262  TJRETHRA,    STRICTURE    OF. 

hour  before  surgeon's  attempts  to  pass  an  instrument.  6.  During  cathe- 
terism,  expose  only  the  genital  organs.  Cover  trunk  and  arms  with  blan- 
kets. 7.  Give  ether.  8.  Commence  vnth  the  very  finest  soft  French  bougie 
you  possess.  If  you  have  not  a  fihform  one,  snip  off  the  bulb  of  a  "  bougie 
a  boule."  9.  While  an  assistant  is  in  the  very  act  of  injecting  oil  into  the 
urethra,  glide  your  bougie,  by  the  side  of  the  nozzle  of  the  syringe,  dovrn 
to,  and  if  possible  through,  the  stricture.  10.  If  that  fails,  try  a  catgut ; 
but,  if  there  are  false  passages,  pass  a  No.  6  gum-elastic  down  to  the  stric- 
ture, and  glide  your  fihform  bougie  down  by  its  side.  11.  As  a  rule,  a 
perfectly  new  filiform  bougie  answers  best,  but  occasionally  the  surgeon 
finds  an  individual  one  of  particular  merit,  which  he  treasures  up  and  uses 
again  and  again.  12.  As  the  oiifice  of  the  stricture  is  not  always  in  the 
axis  of  the  urethra,  the  instrument  should  be  conducted  carefvilly  first 
along  one  side  of  that  passage,  then  on  the  other,  then  along  the  roof,  then 
along  the  floor.  The  soft  instruments  can  only  be  used  in  this  way  when 
the  stricture  is  very  near  the  meatus.  Deeper  strictures,  when  eccentric 
in  position,  require  the  silver  catheter.  (Thompson's  probe-pointed  cathe- 
ter should  be  employed).  13.  When  an  instrument  has  been  passed  at 
last,  but  with  gi'eat  difficulty,  it  should  be  left  in  a  considerable  time,  say 
forty-eight  hours,  caTeful  note  being  made  of  the  particular  manceuvr-e 
which  proved  successful.  Instead  of  withdrawing  it  to  make  room  for  a 
larger  size,  a  Wakley's  tube  can,  with  advantage,  be  passed  over  it.  Wak- 
ley's  tubes  are  of  various  sizes,  and  glide  over  the  originally  introduced 
catheter,  which  acts  to  them  as  a  guide.  14.  Whatever  method  is  tried 
should  have  a  fair  trial.  Fickleness  is  very  likely  to  result  in  failure.  15. 
The  attempts,  if  necessary,  may  be  renewed  on  a  future  day.  Suppose, 
however,  one  of  those  rare  cases  of  genuine  impermeability.  The  stricture 
may  be  near  the  meatus.  Of  course  there  will  be  false  passages.  In  such 
a  case  I  saw  ]\Ir.  Furneaux  Jordan  pass  a  very  sharp,  fine-pointed  bistoury 
into  the  glans  where  the  meatus  ought  to  have  been  (the  meatus  was  itself 
occluded,  and  the  last  quarter  or  half  inch  of  the  urethra  too),  and  fortu- 
nately or  skilfully  hit  the  urethra  beyond.  No  trace  of  a  meatus  had  re- 
mained, the  sui'face  of  the  glans  being  merely  cicatricial  tissue.  If  the 
impermeable  stricture  be  in  the  penile  part  of  the  urethra,  but  not  near 
the  meatus,  divide  it  subcutaneously,  that  is,  pass  a  grooved  director  down 
to  the  stricture.  Feel  the  size  and  position  of  the  stricture  with  the  finger 
and  thumb,  from  the  outside.  Then,  observing  your  landmarks  carefully, 
and  having  the  penis  well  and  steadily  held  up  on  your  director,  pass  a 
sharp  tenotome  through  the  skin  opposite  the  end  of  the  director.  Next, 
without  enlarging  the  skin-wound,  and  cutting  always  in  the  middle  Hne, 
divide  the  stricture.  "When  the  tenotome  has  once  reached  the  urethra  on 
the  proximal  side  of  the  stricture,  the  division  can  be  accurately  and  thor- 
oughly completed  on  a  grooved  staff.  For  genuine  impermeable  stricture 
in  the  bulbous  part  of  the  urethra,  perineal  section  must  be  done,  or  the 


URINE.  263 

bladder  may  be  punctiired,  after  which  catheterization  may  be  possible, 
owing  to  the  repose  which  the  stricture  thus  gets  from  pressure  a  tergo. 
For  treatment  of  Retention,  see  Retention  of  Urine. 

Perineal  Section. — This  operation  resembles  external  urethrotomy,  but 
differs  from  it  in  that  the  stricture,  being  impermeable,  is  not  divided  on  a 
staff,  but  is  carefully  dissected  through.  The  surgeon  requires  an  excel- 
lent light.  He  should  use  all  his  knowledge  of  anatomy,  constantly  refer 
to  the  landmarks  which  are  visible  or  palpable,  and  will  do  well  to  make 
the  starting-point  of  his  dissection  the  juncture  of  the  distal  part  of  the 
urethra  with  the  stricture,  a  point  which  can  be  fixed  by  the  end  of  a  staff 
passed  down  to  it.  Work  throughout  in  the  exact  median  plane  of  the  body. 
The  details  of  this  operation  have  been  admirably  worked  out  by  Wheel- 
house,  of  Leeds.  He  uses  a  staff  with  a  button-Hke  end.  Urethra  is  opened 
a  quarter  of  an  inch  in  front  of  stricture,  the  orifice  of  the  latter  being  then 
searched  for  with  the  probe.     See  British  Medical  Journal,  June  24,  1876. 

Accidents  of  Stricture  are  perineal  abscess,  perineal  fistula,  penile  or 
ante-scrotal  fistula,  retention  of  urine,  each  of  which  is  noticed  in  its  al- 
phabetical place. 

False  Passage  is  a  common  effect  of  rough  catheterism.  Treatment. — If 
there  is  retention,  the  bladder  may  be  reached  sometimes  by  passing  first 
one  middle-sized  instrument,  then  a  fine  catheter  beside  it.  Otherwise,  it 
is  best  to  suspend  attempts  at  passing  instniments  till  the  false  passage 
has  had  time  to  heal.  An  instrument  in  a  false  passage  moves  freely,  one 
in  a  stricture  is  gripped  more  or  less  tightly.  Macleod,  of  Glasgow,  rec- 
ommends a  course  of  quinine  during  the  treatment  of  stricture.  It  is  not 
unreasonable  to  think  that  it  might  act  as  a  prophylactic  against  septicae- 
mia. 

Urine. — Normal  urine  is  clear,  pale  amber-colored,  of  specific  gravity 
not  greater  than  1030,  and  acid  in  reaction.  It  does  not  respond  to  the 
tests  either  for  albumen  or  for  sugar,  and  it  does  not  deposit  urates  as  it 
cools.  Fi-om  thirty  to  fifty  ounces  are  usually  passed  in  the  twenty-four 
hours. 

The  chief  urinary  deposits  are  urates,  phosphates,  and  oxalates,  casts  of 
the  renal  tubuli,  mucus,  and  pus.  Blood  may  be  diffused  in  the  urine,  or 
even  be  passed  per  urethram,  almost  unmixed  with  urine.  Grape  sugar  may 
be  present  in  solution.  Epithelium,  bile-acids,  bile-pigment,  spermatozoa ; 
certain  constituents  of  the  food  may  also  be  found,  e.g.,  in  the  strong-smell- 
ing urine  passed  after  eating  asparagus.  The  acidity  of  healthy  urine 
probably  due  to  presence  of  acid  sodium  phosphate.  When  a  free  acid  is 
present,  "  the  reaction  to  test-paper  is  far  stronger,  and  the  liqiaid  deposits 
on  standing,  little,  red,  hard  crystals  of  uric  acid  ;  but  this  is  no  longer  a 
normal  secretion "  (Fownes'  "  Chemistry,"  eleventh  edition).  Alkalinity 
of  healthy  urine  very  rare,  and  then  due  to  neutral  potash  or  soda  salts 
of  vegetable  acids  {e.g.,  tartrates,  citrates,  and   acetates)  taken  into   the 


264  URINE. 

stomach.  Alkalinity  in  retention  cases  is  due  to  fermentation,  which 
forms  ammonium  carbonate  from  urea.* 

Urates  usually  red,  but  vary  from  pale  yellow  to  purplish.  Readily 
dissolved  by  heat. 

Phosphates  may  be  thrown  down  from  neutral  urine  by  boiling,  but 
dissolve  instantly  when  a  drop  of  nitric  acid  is  added.  Contrast  with  al- 
bumen. Phosphates  are  most  abundant  in  the  alkaline,  mucopurulent 
urine  of  chronic  cystitis. 

Oxalate  of  Lime  is  recognized,  under  the  miscroscope,  by  its  dumb- 
bell and  octahedral  crystals. 

Benal  Casts,  found  often  in  albuminous  urine.  Basis  usually  fibrin. 
May  be  waxy  or  fatty.  May  contain  blood  or  pus-corpuscles  or  epithelial 
cells. 

Mucus  may  occasionally  come  from  the  prostatic  urethra,  and  conse- 
quently be  only  accidentally  mixed  with  the  urine.  Patient  then  generally 
passes  it  toward  end  of  act  of  micturition.  But  mucus  and  pus,  existing 
together,  are  usually  accompanied  also  by  phosphates  and  an  alkahne  re- 
action.    Ui'ine  reacts  also  to  tests  for  albumen. 

Pus,  unmixed  with  mucus,  if  diffused,  is  probably  from  kidney  ;  if  not 
diffused,  is  from  an  abscess  opening  into  bladder  or  urethra. 

Blood  in  the  xu'ine  may  come  from  kidney,  ui'eter,  bladder,  or  urethra. 
Very  unlikely  to  come  from  ureter,  even  in  case  of  injury  to  abdomen.  If 
renal,  blood  is  diffused,  producing  "  smoky  "  urine  ;  if  vesical,  less  likely 
to  be  entirely  diffused,  almost  sure  to  pass  partly  pure ;  if  urethral,  is  likely 
to  pass  quite  independently  of  urine,  sometimes  without  micturition,  some- 
times immediately  after  micturition.  Bloody  urine  is  necessarily  albumi- 
nous. Sham  haematuria  sometimes  produced  with  coloring  matters  by 
impostors. 

Grape  Sugar  increases  specific  gravity  of  urine,  imparts  a  sweet  odor, 
and  increases  flow  of  urine  (diabetes).  Trommer's  test  :  add  a  few  drops 
of  solution  of  cupric  sulphate  to  lu'ine,  then  add  excess  of  liq.  potassse, 
lastly  boil ;  a  red  precipitate  (cuprous  oxide)  is  quickly  thrown  down. 
Pavy's  test-pellets  are  handy. 

Bile-pigment. — In  cases  of  jaundice,  sufficient  bilirubin  may  exist  in 
urine  to  answer  to  Gmelin's  test.  "  Treated  with  oxidizing  agents,  such  as 
nitric  acid  yellow  with  nitrous  acid,  it  displays  a  succession  of  colors  in 
order  of  the  spectrum.  The  yellowish  golden  red  becomes  green,  this  a 
greenish  blue,  then  blue,  next  violet,  afterward  a  dirty  red,  and  finally  a 
pale  yellow  "  ("Foster's  Physiology"). 

Epithelium  and  Spermatozoa,  as  well  as  casts  and  crystals,  are  discovered 
by  the  microscope. 

For  the  value  of  the  above  deposits,  etc.,  see  the  sections  treating  on 

'  In  addition  to  what  follows,  concerning  urinary  deposits,  see  Calculus. 


UEINE.  265 

Diseases  and  Injuries  of  Bladder  and  Urethra,  Abdominal  Injuries,  Impo- 
tence, Calculus. 

Ukine,  Eetention  of. — A  term  applied  only  to  acute  stoppage  of  the 
urethra,  and  never  to  mere  habitual  difficulty  in  urination.  Varieties. — (1) 
Retention  from  organic  stricture,  (2)  from  inflammation,  (3)  from  spasm, 
(4)  from  internal  obstruction,  e.g.,  by  calculus,  (5)  from  external  pressure, 
e.g.,  by  abscess,  (6)  from  enlarged  prostate,  (7)  from  hysteria,  (8)  from  op- 
erations on  pelvic  or  even  on  distant  regions.  Causes. — Partly  indicated 
in  the  last  sentence.  But  the  exciting  cause  of  retention,  whether  purely 
spasmodic,  or  arising  in  the  course  of  organic  stricture,  or  of  gonorrhoea 
(inflammatory  retention),  is  usually  drink  or  exposure  to  cold.  Besides 
gonorrhoea,  various  drugs,  e.g.,  cantharides,  ergot,  and  even  quinine,  will 
sometimes  temporarily  close  the  urethra  (by  spasm  or  inflammatory  eflii- 
sion  or  by  both  ?).  The  predominance  of  certain  causes  depends  greatly 
on  the  age.  In  childi'en  the  least  rare  are  impaction  of  a  calculus  or  a  for- 
eign body,  a  string  tied  around  penis,  an  injury  to  the  perinaeum,  abscess, 
phimosis,  and  adherent  prepuce.  In  adults  the  most  common  are  alcohol 
and  cold  during  organic  stricture  or  gonorrhoea.  Earely  too  strong  ure- 
thral injections.  In  old  age  the  chief  cause  is  prostatic  hypertrophy. 
Symptoms. — An  adult  in  his  senses  of  course  knows  that  he  cannot  pass 
his  urine  properly.  But  adults  when  delirious,  or  prostrate,  or  insensible, 
and  children  when  young,  may  present  no  direct  or  striking  sign  of  reten- 
tion unless  it  be  looked  for.  The  bladder  usually  rises  in  the  abdomen,  mak- 
ing dull  successively  the  hypogastric  and  even  the  umbilical  regions.  But 
in  old  cases  of  stricture,  the  bladder  may  be  organically  so  contracted  that 
it  would  rupture  before  distending  enough  even  to  rise  out  of  the  pelvis. 
Diagnosis. — The  most  dangerous  mistake  is  that  of  taking  a  case  of  reten- 
tion with  overflow  for  one  of  pure  incontinence.  Always  catheterize  if 
there  be  the  slightest  doubt.  In  suppression  of  urine  the  bladder  is 
nearly  or  quite  empty,  and  the  symptoms  belong  rather  to  the  kidneys  and 
nervous  system  (e.g.,  lumbar  pain  and  afterward  coma),  than  to  the  blad- 
der and  urethra.  Prognosis. — If  unrelieved,  great  danger  of  rupture  of 
urethra,  extravasation  of  urine,  urinary  abscess  and  fistula,  or  even  gan- 
grenous cellulitis  and  death.  But  -this  does  not  apply  to  hysterical  reten- 
tion ;  nature  usually  remedies  that  herself  after  a  time.  Treatment.  — Hot 
bath  (104°),  liq.  opii,  TTi  xx.,  then  bed  and  warm  blankets.  Catheterize 
at  once  (except  in  hysterical  cases).  For  spasmodic  strictirre  use  a  No.  5 
soft  French  catheter  warmed  by  friction  and  well  oiled.  For  organic 
stricture  try  the  same  instmiment.  If  it  does  not  pass  at  once  adopt  the 
measures  detailed  on  pp.  262  and  263.  If  they  fail  to  lead  you  to  the  blad- 
der, and  if  his  retention  be  complete  or  nearly  so,  the  patient  must  not 
be  left  unrelieved.  Aspiration  above  the  pubes  is  perhaps  the  safest  and 
best  means  of  affording  inmiediate  relief.  Other  methods  are  (1)  supra- 
pubic pvmcture  with  a  small  trochar  and  canula,  directed  backward  and 


266  VAGINA. 

downward,  (2)  puncture  per  rectum,  (3)  opening  the  uretkra  behind  the 
stricture,  (4)  "perineal  section"  pi*oper,  i.e.,  without  a  guide.  If  the  sur- 
geon never  hopes  to  open  the  urethra  satisfactorily  again,  he  had  better 
perhaps  adopt  plan  1.  If  he  knows  the  stricture  to  be  of  that  class  for 
which  Syme  recommended  external  urethrotomy,  and  if  he  have  confi- 
dence in  his  own  skill,  he  is  justified  in  attempting  to  cure  both  retention 
and  stricture  by  plan  4.  In  other  cases  his  choice  undoubtedly  is  practi- 
cally confined  to  aspiration  and  pvmcturing  per  rectum.  When  retention 
is  caused  by  impaction  of  a  calculus  or  foreign  body,  the  obstruction  must 
be  withdrawn  if  possible  ;  but  if  it  cannot  be  extracted  per  urethram,  it 
had  better  be  pushed  back  into  the  bladder,  and  reserved  for  further  treat- 
ment, e.g.,  crushing  by  litho trite,  or  extraction  through  a  median  perineal 
incision. 

Uvula,  Clefc. — Slightest  grade  of  cleft  palate.  Pare  edges  and  imite 
with  fine  sutures. 

Uvula,  Relaxed. — ^Usually  part  of  a  general  condition  of  pharyngeal 
catarrh.  Often  causes  troublesome  cough.  Astringent  gargles.  Touch 
with  silver  nitrate.  Tonics.  Stomachics.  Attack  cause,  e.g.,  over-indul- 
gence of  any  kind.     Or  seize  the  extremity  with  forceps  and  cut  it  off. 

Vagina,  Imperforate. — Usually  a  mere  adhesion  of  opposite  vaginal 
•walls,  easily  torn  open,  and  prevented  fi'om  readhering  by  oiled  cotton- 
wool. Not  to  be  confoimded  with  a  very  seiious  malformation,  viz.,  Im- 
perforate Hymen.  This  latter  condition  causes  retention  of  the  menstrual 
fluid  till  long  after  puberty.  The  treatment  is  to  open  by  incision.  Dan- 
ger of  resultant  inflammation  spreading  to  peritoneum.  (Open  with  anti- 
septic precautions).  Vagina  may  be  a  mere  cul-de-sac,  associated  with  ar- 
rested decelopment  of  uterus  and  ovaries.  To  diagnose  the  latter  condition, 
examine  (1)  with  catheter  in  bladder  and  finger  in  rectum,  (2)  with  specu- 
lum.    Nothing  can  be  done. 

Abseyice  of  Vagina  occurs  in  rare  instances. 

Vaginal  Fistula. — (1)  Vesico-vaginal,  (2)  urethro-vaginal,  (3)  recto- 
vaginal. Causes. — Laceration  or  sloughing,  the  result  of  difficult  labor, 
or,  more  rarely,  of  accident.  Syphilis.  (Fistulse  from  cancer  are  so  irre- 
mediable as  to  be  best  not  considered  here.)  Symptoms. — Incontinence 
of  urine  or  of  faeces.  But  the  latter  may  not  occur  imless  the  rent  is  very 
large  or  the  faeces  fluid.  Flatus  may  escape  and  Httle  or  no  fseces.  Seat 
and  extent  of  fistula  must  always  be  determined  by  combined  digital 
and  specular  examination.  Catheter  often  useful.  Treatment. — Pm-ely 
operative.  Cautery  may  be  tried  in  very  trivial  cases.  Instruments. — 
Duck-bill  speculum,  long  straight  and  long  angular  knives,  long  forceps,  tu- 
bular needles,  with  Startin's  handle,  wire-twister,  long  curved  scissors,  long 
soft  india-rubber  catheter,  silver  vnre,  silk,  handled  sponges,  etc.  Chief 
points  of  operation  are  ten:  (1)  Health  good.  (2)  Eectum  empty.  (3)  Po- 
sition— lithotomy.  (4)  Nates  held  widely  apart  by  assistant    (5)  Duck-bill 


VAGINA.  267 

speculum.  Operator  will  occasionally  hold  this  himself,  but  usually  hand 
it  to  an  assistant.  (6)  Drag  the  fistula  toward  the  vaginal  orifice.  This 
may  be  done  in  various  ways,  e.g.,  with  a  blimt  hook,  or  by  one  of  the  su- 
tures. (7)  Thoroughly  pare  the  edges  on  the  vaginal  side  ;  (8)  but  do  not 
meddle  with  vesical  mucous  membrane.  (9)  Sutures  must  not  enter  blad- 
der, nor  be  pvilled  too  tight.  (10)  Sutures  should  enter  and  leave  about 
half  an  inch  from  edges  of  wound.  As  soon  as  operation  is  done,  place, 
secure,  and  leave  flexible  catheter  in  bladder.  This  should  be  cleaned 
twice  daily.  Patient  now  lies  on  her  side.  Unless  imtoward  symptoms 
arise,  leave  sutures  in  ten  days. 

Operation  for  recto-vaginal  fistula  is  precisely  similar.  Keep  bowels 
confined  for  ten  days.  "  Whether  or  not  the  sphincter  ani  should  be  di- 
vided will  depend  on  the  degree  of  tension  which  is  present  when  the 
parts  are  brought  together.  It  is  not  a  slight  measure  and  should  not  be 
heedlessly  resorted  to  "  (Hutchinson  in  Holmes's  "  System  ").  Wash  out 
vagina  daily  with  a  syphon.  In  operations  about  the  vagina,  remember  the 
erectile  tissue  which  lies  immediately  beneath  the  mucous  membrane,  and, 
therefore,  remove  the  latter  with  delicacy,  to  avoid  hemorrhage.  Such 
hemorrhage  I  have  seen  instantly  controlled  by  hot-water  injections  (temp. 
120°-130°  Fahr.). 

Vagina,  Foreign  Bodies  in,  generally  pessaries  or  sponges,  may  cause  a 
false  diagnosis  of  metritis,  leucorrhcea,  or  even  cancer,  patient  forgetting 
their  presence.  Sometimes  they  have  to  be  removed  piecemeal.  Pessa- 
ries have  for  years  remained  unsuspected  in  the  vagina,  causing  foul  dis- 
chai'ge,  etc. 

Vagina,  Infantile  Tumoes  of. — Very  rare.  See  T.  Holmes  in  his  "  Sys- 
tem," vol.  v.,  p.  851. 

Vagina,  Lacerations  of. — Usually  the  result  of  parturition,  occasionally 
caused  by  broken  chamber-utensils  or  by  assaults,  etc.  ;  in  rare  instances, 
even  by  bridal  intercourse.  Treatment. — Trivial  cases  require  only  rest, 
silver  nitrate,  etc. ;  meditim  cases  require  sutures,  and,  if  neglected  at  first, 
eventually  operation  for  recto-  or  vesico-vaginal  fistula.  Severe  cases  may 
cause  collapse  and  rapid  death.  Complete  circular  rupture  of  vagina,  with 
expulsion  of  uterus,  has  been  known  during  parturition  !  And  this,  also, 
without  violent  instrumental  interference. 

Vaginal  Prolapsus, 

Vaginal  Tumors  of  Adults,  and 

Vaginal  Discharges,  non-Gonorrhceal,  are  apt  to  be  so  intimately  con- 
nected with  uterine  affections  that  they  are  most  fully  treated  in  Gjmeco- 
logical  works. 

Non-specific  Vaginitis  of  Children  may  cause  evil  suspicion  ;  but  the 
affection  should  always  be  presumed  to  be  innocent,  unless  there  is  col- 
lateral evidence  to  the  contrary.  Cause. — In  some  cases  the  passage  of 
thread-woima   from  rectum   to  vagina,   and  local  irritation.      Struma? 


268  VARix. 

Treatment. — Local  cleanliness,  dryness,  and  mild  astringents.     Attend  to 
general  health. 

Varicocele. — Sometimes  no  less  than  seven  causes  of  varicocele  are 
given  !  And  all  these  exist  in  every  healthy  indi%adual,  old  or  young,  yet 
varicocele  is  almost  unknown  in  young  childi'en  and  old  people.  Quite  suf- 
ficient causes  are  to  be  found  in  the  lax  nature  of  the  scrotum,  and  in  the 
amount  of  violent  congestion  to  which  the  spermatic  veins  are  subject  in 
many  young  adults.  The  left  side  is  oftenest  affected.  Several  reasons 
have  been  given,  e.g.,  rectangular  junctiu-e  of  left  spermatic  vein  with  re- 
nal, and  relation  of  former  vein  to  sigmoid  flexure  of  colon.  Neither  of 
these  reasons  will  bear  strict  criticism.  The  left  side  of  the  scrotum  is 
almost  always  larger  than  the  right,  and  therefore  laxer,  as  the  left  testicle 
is  no  larger  than  the  right.  The  veins  are  enlarged,  lengthened,  and 
thickened.  The  enlarged  veins  coil  around  the  cord  and  against  the 
testicle  in  such  a  way  as  to  feel  "  like  a  bag  of  worms."  Increase,  on 
standing.  Decrease  on  lying  down.  Impulse  (slight)  on  coughing.  Often 
aching  pain  and  tenderness.  Depression  of  spii'its.  Treatment. — I  bieg 
to  recommend  the  suspensory  bandage  which  I  have  myself  contrived. 
If  properly  fitted,  it  removes  the  venous  congestion  as  soon  as  applied, 
and  will  often  substitute  for  low  spii'its  and  aching  joain  a  feeling  of 
brightness  and  of  being  well  braced  up.  Other  local  apparatus  are 
Wormald's  ring,  the  common  suspensory  bandage  (generally  ine£Scient), 
Morgan's  (of  Dublin)  suspender  ;  an  inguinal  truss  (which  is  said  to  "sus- 
tain "  the  column  of  blood  above,  though  it  manifestly  must  equally  ob- 
struct the  flow  of  blood  from  below).  Cold  douching.  Attention  to  the 
digestive  system  and  bowels.  Correction  of  evil  habits.  Operations  for 
varicocele  are  riot  unpopular  with  some,  who,  by  good  luck,  have  had  no 
shocking  accident  from  embolism.  Operation  is  justifiable  when  a  patient 
finds  it  urgently  desirable  to  pass  into  the  public  service  witliout  delay,  or 
when  a  varicocele  causes  severe  symptoms  and  will  not  yield  to  milder 
measures.  Atrophy  of  the  testicle  said  to  be  caused  by  varicocele.  Many 
of  the  effects  attributed  to  varicocele  in  certain  cases  are  quite  as  much 
due  to  genital  irritation  of  which  the  varicocele  is  itself  a  result.  Opera- 
tions.— Two  kinds  and  many  varieties.  Both  subcutaneous,  in  one  the 
veins  are  merely  constricted,  in  the  other  they  are  constricted  at  two  points 
and  divided  intermediately.  The  vas  deferens  (easily  recognized  by  its 
cord-like  feel)  must  be  slipped  well  out  of  the  way  :  the  spermatic  artery 
lies  close  to  it.  Lee's  operation  is  probably  as  good  as  any.  In  it  the 
veins  are  constricted  in  two  places  by  needles  beneath  them  and  figure-of- 
8  ligatures  over  them.  As  these  ligatures  are  not  subcutaneous,  they  must 
not  be  tight.  A  tenotomy  knife  divides  the  veins  intermediately.  On  the 
6th  day,  remove  needles.    Bed  for  three  weeks :  then  suspensorj'  bandage. 

Varix. — Dilatation  of  veins.     Causes. — Mechanical  obstruction    {e.g., 
varix  of  saphena  from  pressure  of  pregnant  womb  on  external  iliac  vein). 


VEINS.  269 

Occupations  in  wliicli  there  is  much  standing,  e.g.,  those  of  laundress  and 
shopwoman.  Such  influences  as  the  above  act  chiefly  on  persons  with  an 
individual  or  a  family  predisposition,  and  on  certain  localities,  namely 
saphenous  and  spermatic  veins,  and  their  radicles.  It  is  said  that  the  deep 
veins  of  the  legs  are  nearly  as  often  affected  as  the  superficial.  Frequently 
the  minute  cutaneous  venous  radicles  are  alone  affected.  This  often  occurs 
in  the  face,  and  is  frequently  hereditary.  Pai/ioZo^r?/. —Hypertrophy  as 
well  as  dilatation  of  the  veuous  coats,  of  the  muscular  as  well  as  the  fibrous 
elements.  Dilatation  sometimes  regular,  sometimes  saccular.  Extent 
varies  from  a  small  part  of  one  vein  to  nearly  all  the  veins  of  one  or  both 
lower  extremities.  As  the  valves  do  not  grow  pi-oportionally,  they  soon 
become  insufficient.  Thickening  of  connective  tissue  round  the  veins. 
This  may  increase  to  general  thickening  of  whole  limb.  (Edema  from 
difficulty  of  circulation  through  the  dilated  veins  with  inefficient  valves, 
ffidema  leads  to  eczema :  eczema  to  "varicose  "  ulceration.  Occasional  burst- 
ing and  hemorrhage.  This  may  lead  to  ulceration.  Coagulation  in  certain 
parts  of  the  vein,  generally  near  valves,  "phlebolites."  Symptoms. — No  per- 
son who  has  seen  one  varicose  vein  can  fail  to  recognize  another  ;  but  when 
such  a  vein  is  sui'rounded  by  brawny  tissue  it  may  escape  the  sight :  it  can 
then  be  felt  as  a  soft,  subcutaneous  "channel."  Color  varies  from  flesh- 
color  to  purple  ;  usually  bluish  gray.  Aching  pain  after  long  standing, 
Varix  of  spermatic  vein  may  cause  neuralgia  and  mental  depression.  See 
Vancocele,  above.  Varicose  veins,  when  inflamed,  become  hot,  tender,  etc. 
Prognosis. — Easy  to  alleviate.  Almost  impossible  to  cure  without  opera- 
tion— which  is  i-arely  justifiable  (or  entirely  effectual  when  disease  is  ex- 
tensive). Treatment. — Suj^port  by  pressure  of  (1)  elastic  bandages,  (2) 
elastic  stockings,  (3)  common  bandages — preferably  starched,  (4)  strong 
lace-up  stockings.  Avoid  standing  or  long  sitting  with  legs  dependent. 
Regular  but  moderate  walking  with  legs  well  bandaged.  Attend  to  bowels 
and  general  health.  Iron.  Horizontal  rest  in  middle  of  day  for  an  hour  or 
two.  Bathing  in  cold  water  after  exercise.  Elastic  stockings  should  fit  well, 
and  are  somewhat  expensive,  since  they  do  not  wear  so  long  as  bandages. 
Operations. — A  proceeding  similar  to  one  or  other  of  those  described  above 
under  head  of  varicocele,  is  aj)plied  to  as  many  parts  of  a  varicose  vein  as 
may  be  required  to  obliterate  it,  e.g.,  the  vein  may  be  compressed  in 
several  places  between  needles  passed  beneath  it  and  strips  of  india-rubber 
stretched  over  it  (outside  the  skin),  and  subcutaneously  divided  between 
the  points  of  acujoressure  (Lee).  Caustics  and  injection  of  a  drop  or  two 
of  perchloride  of  iron  have  been  used  and  recommended,  the  latter  as  an 
adjunct  to  acupressure  (Bryant).  Operation  of  excision  of  varicose  vein 
with  antiseptic  precautions  (spray,  etc.)  is  much  practised  at  Guy's  Hos- 
pital by  Howse  and  others.  It  is  neatly  described  by  Dunn  in  "  St.  Bar- 
tholomew's Hospital  Reports,"  1879. 

Veins,  Inflammation  of. — A  subject  which  in  most  surgical  works  ia 


270  VEINS. 

considered  as  if  inseparable  from  Thrombosis.  The  separation  is  really 
difficult;  but  the  mixture  generally  plunges  the  cautious  student  into 
doubt  and  confusion  as  to  what  he  is  really  reading  about.  Let  it  be  pre- 
mised that  (1)  inflammation  of  a  vein  is  apt  to  lead  to  thrombosis  in  it,  but 
does  not  necessarily  do  so  ;  (2)  that  it  is  sometimes  impossible  to  diagnose 
whether  a  given  case  is  phlebitis  with  or  phlebitis  without  thrombosis ;  (3) 
that  thrombosis  is  almost  sure,  unless  quickly  resolved,  to  lead  to  changes 
in  the  vein  obstructed ;  (4)  that  many  cases  called  phlebitis  are  really 
cases  of  periphlebitis,  i.e.,  of  inflammation  of  the  cellular  tissue  around 
the  vein  ;  (5)  that  the  concurrence  of  thrombosis  is  generally  the  most 
serious  part  of  a  case  of  phlebitis.  Hence  in  treating  any  case  of  phlebitis 
or  perii^hlebitis,  the  idea  of  thrombosis  and  of  its  possible  consequences 
— e.g.,  solid  oedema  and  pyaemia — never  leaves  the  surgeon's  mind. 

Phlebitis. — Causes. — Injury,  e.g.,  phlebitis  of  saphena  following  a  dog- 
bite,  thrombosis  or  embolism,  gout,  obsciu-e  influences,  possibly  presence 
of  irritating  materials  in  the  blood.  Varicose  veins  particularly  liable. 
Paget,  classifying  phlebitis  according  to  its  causes,  gives  eight  kinds,  viz.  : 
(1)  from  injury,  (2)  from  exhaustion,  (3)  from  propinquity  of  inflamed  or 
otherwise  diseased  parts,  (4)  rheumatic,  (5)  pyremial,  (6)  puerperal,  (7) 
gouty,  (8)  from  poisoning  by  foul  drains.  Some  of  these  causes  are  quali- 
fied in  the  original  lecture.  See  Paget's  "  Clinical  Lectm-es."  Si/mjMms. 
— Redness,  hai'd  swelling,  tenderness,  more  or  less  pain  in  the  course  of 
a  vein  or  of  part  of  a  vein.  Swelling  sometimes  knotty,  knots  said  to  cor- 
respond to  seat  of  valves.  (Edema  in  parts  whence  the  vein  should  drain 
blood.  Sometimes  visible  enlargement  of  collateral  veins.  If  suppuration 
occurs,  there  is  local  softening  and  general  rise  of  temperature.  Perhaps 
a  rigor.  Diagnosis  has  chiefly  to  be  made  from  lymphangitis.  It  depends 
on  the  situation  of  the  redness,  etc.,  and  on  the  width  of  the  band  of  in- 
flammation (gi-eater  in  phlebitis).  Glands  also  more  likely  to  be  enlarged 
in  lymphangitis.  Pathology. — Inflammation  of  the  vein  itself  is  almost  al- 
ways preceded  by  thrombosis ;  and,  when  not  preceded  by  thrombosis,  it  is 
probably  secondary  to  periphlebitis.  The  experiments  of  modern  pathol- 
ogists, e.g.,  Lee  and  Callender,  certainly  prove  that  the  older  pathologists 
were  accustomed  to  mistake  mere  thrombosis  for  an  exudation  of  lymph 
from  the  wall  of  the  vessel,  but,  to  my  mind,  considering  the  anatomy  of 
the  veins,  and  arguing  analogically,  they  are  not  numerous  and  severe 
enough  to  prove  that  exudation  of  lymph  never  takes  place  ;  and  they  most 
assuredly  do  not  justify  the  dismissal  of  true  phlebitis  from  our  nosology. 
But  any  thickening  of  the  outer  or  of  the  middle  coats,  or  roughness  of  the 
inner  coat  of  an  inflamed  vein,  is  so  rarely  found,  independently  of  throm- 
bosis, and  is,  in  itself,  of  such  small  importance,  that  the  most  interesting 
pathological  features  associated  with  phlebitis  must  be  sought  for  under 
the  head  of  venous  thrombosis.  Prognosis. —  Vide  Venous  Thrombosis. 
Treatment. — Eest.     Elevation,  gentle  and  even   pressure.     If  a  common 


VEINS.  271 

roller  be  used,  place  a  layer  of  cotton-wool  beneath  for  tlie  sake  of  elas- 
ticity. Kegulate  bowels.  Moderate  or  low  diet.  If  abscess  threatens,  it 
may  be  poulticed,  fomented  with  hot  water,  and  opened  early.  Extensive 
cases  of  solid  oedema  from  venous  obstruction  are  rarely  entirely  cured, 
some  thickening  remaining.  As  ammonia  readily  enters  the  blood  and, 
when  there,  retards  coagulation,  there  is  a  rational  indication  for  giving  it 
in  cases  of  phlebitis.  I  believe  Dr.  Richardson  has  demonstrated  its  value 
in  cases  of  thrombosis.  The  carbonate  in  large  doses  would  be  the  best 
form  to  administer. 

Concerning  gouty  phlebitis,  Paget  says  it  is  "  either  associated  with  or- 
dinary gouty  inflammation  in  the  foot  or  joints,  or  occurs,  with  little  or  no 
evident  provocation,  in  persons  of  mai'ked  gouty  constitution  or  with  gouty 
inheritance.  Not  rarely  it  has  peculiar  marks,  especially  in  its  symmetry, 
apparent  metastases,  and  frequent  recurrences."  Treatment. — Employ 
same  means  as  in  managing  gout  affecting  other  external  parts,  esjDecially 
rest  and  elevation.  When  vein  affected  is  large,  rest  should  continue  a 
month  from  date  of  last  marked  attack  of  pain,  to  lessen  risk  of  embolism. 

Venous  Thrombosis. — Formation  of  a  clot  in  a  living  vein.  Causes. — (1) 
Injui-y  to  a  vein,  e.g.,  a  wound.  This  may  act  either  by  causing  a  rough- 
ness or  projection  into  the  calibre  of  the  vein,  or  by  obstructing  the  flow 
of  blood  altogether.  (2)  Constriction.  This  is  probably  the  way  in  which 
inflammation  external  to  the  vein  usually  acts  :  the  immediate  effect  is  to 
slow  the  blood-current.  (3)  Dilatation,  by  retarding  the  flow  of  blood, 
will  produce  thrombosis,  e.g.,  occasionally  in  varicose  veins.  (4)  Another 
cause  analogoiis  in  mode  of  action  to  the  last  two  is  constitutional  debil- 
ity, "  marasmic  thrombosis."  (5)  The  entrance  of  an  ii-ritant  or  of  septic 
poison  into  the  blood.  (6)  Thrombosis  in  one  vein  may  be  mei'ely  the  re- 
sult of  extension  into  it  of  a  clot  from  a  neighboring  vein,  e.g.,  in  certain 
cases  of  "white  log,"  obstruction  of  external  iliac  has  spi'ead  up  from  uter- 
ine veins  through  internal  ihac.     (7)  Gout. 

Pathology. — When  first  formed,  clot  usually  small,  rarely  large.  In- 
creases by  laminar  deposits.  Usually  fills  the  vein :  rarely  leaves  a  chan- 
nel beside  it,  i.e.,  between  it  and  the  wall  of  the  vein.  Sometimes  spiral 
in  shape.  Soon  adheres  to  veiu-waU.  (In  all  above  respects,  it  contrasts 
with  post-mortem  clots.)  In  time,  come  (1)  changes  in  the  clot,  (2) 
changes  in  the  vein  itself,  (3)  changes  in  the  peri-venous  tissues.  To 
these  may  be  added  (4)  changes  in  the  parts  formerly  drained  by  the  vein. 
The  clot  may  either  (1)  disintegrate  and  pass  into  the  circulation,  or  (2) 
organize  into  a  fibrous  band  united  with  the  vein,  or  (3)  that  part  of  it 
first  formed  may  melt  into  a  puriform  fluid — differing  from  true  pus  in 
containing  granular  debris  and  not  corpuscles.  In  this  case  the  poi-tion  of 
clot  last  formed  almost  invariably  remains  to  shut  off  the  liquefied  part 
from  the  circulation,  or  (4)  the  white  corpuscles  which  wander  into  the  clot 
may,  instead  of  converting  it  into  a  fibrous  mass  (as  in  case  2),  be  the 


272  WHITLOW. 

agents  in  forming  true  pus  within  the  vein,  or  (5)  a  portion  or  the  whole 
of  the  thrombus  may  be  washed  away,  thus  becoming  an  embolus.  "When 
suppuration  occurs  in  the  course  of  a  thrombosis  it  must  be  understood 
that  the  pus  is  usually  in  the  first  instance  outside  the  vein.  The  course 
taken  by  the  vein  and  its  contained  thrombus  is  almost  always  identical 
with  the  changes  taking  place  in  the  cellular  tissue  around  the  vein.  Biag- 
nosis. — See  Vein,  Inflammation  of.  But  thrombosis  may  be  recognized  by 
the  hard  cord-like  feel  of  the  vein  affected,  before  inflammatory  change  has 
commenced,  and  by  the  oedema.  Prognosis. — Varies  most  widely  accord- 
ing to  the  extent  and  position  of  the  clot,  according  to  its  first  cause  (e.g., 
whether  the  mere  ligature  of  a  vein,  or  the  entrance  of  putrid  fluid  into 
it),  and  according  to  the  course  the  case  takes  while  under  observation. 
The  danger  of  embolism  exists  to  a  slight  extent  in  almost  every  case, 
and  of  pyaemia  in  such  as  show  a  tendency  to  local  suppurations  or  as  arise 
in  the  course  of  wounds.     Treatment.  — See  Veins,  Inflammation  of. 

Warts. — See  Papillomata  (under  head  of  Tumors). 

Whitlovr. — Erysipelatous  inflammation  of  finger.  Varies  in  extent 
from  trivial  but  j^ainful  blush  beside  nail,  to  diffuse  suppuration  spreading 
up  forearm  and  destroying  tendons,  phalanges,  and  even  wrist-joint. 
Causes. — Local  punctures,  cuts  and  scratches,  poisonous  or  otherwise. 
Predisposing  causes  are  same  as  those  of  erysipelas,  quod  vide,  e.g.,  low 
state  of  health,  diseased  kidneys,  epidemic  and  endemic  influences.  Pathol- 
ogy. — A  cellulitis,  at  first,  usually,  of  cellular  tissue  around  ungual  pha- 
lanx, but  tending  to  spread  to  sheaths  of  tendons,  to  skin  and  subcutane- 
ous tissues  of  back  of  hand,  and  even,  as  above  stated,  to  phalangeal,  and  in 
the  worst  cases  to  metacarpal  and  still  larger  joints.  May  subside.  Usually 
suppurates.  Local  and  general  efiects  precisely  similar  to  those  of  cellu- 
litis elsewhere.  If  a  phalangeal  joint  be  affected,  or  a  tendon  slough, 
there  will  probably  be  a  stiff  and  contracted  finger  afterward.  Sywptoms. 
— Local  redness,  heat,  throbbing,  pain,  tenderness,  and  swelling.  Feverish- 
ness  in  slight  cases,  prostration  in  severe  ones.  Increased  swelling  and 
oedema  when  pus  has  formed.  As  incision  is  generally  made  early,  and 
the  part  is  exquisitely  tender,  fluctuation  need  not  necessarily  be  felt  for. 
Diagnosis. — Effects  of  a  foreign  body  in  the  finger  or  hand  may  be  mis- 
taken for  a  simple  whitlow.  Prognosis. — Usually  good  as  regards  life, 
even  in  extensive  cases  extending  up  forearm.  Bad  or  good  locally  accord- 
ing to  extent  to  which  tendons  and  joints  are  affected.  Treatment. — Best, 
local  and  general.  Elevation  and  flexion ;  carry  hand  in  sling  just  be- 
neath chin.  Pressure  on  brachial  artery  :  patient  can  be  taught  to  make 
it  with  the  thumb  of  his  sound  hand.  Poultices  :  frequent  hot  fomenta- 
tions. After  forty-eight  hours,  if  symptoms  are  unrelieved,  make  two 
longitudinal  incisions,  one  on  each  side  of  palmar  surface  of  finger  (of 
course,  excepting  those  slight  cases  where  this  part  remains  unaffected). 
Give  a  purgative,  e.g.,  calomel,  gr.  x.,  afterward  iron  (tinct.  ferri  perchlor., 


WOUNDS.  273 

iTj,  XV,  ter  d.  s.).  Regulate  diet  according  to  patient's  condition  and  con- 
stitution. As  a  rule  avoid  meat.  Appetite  is  generally  bad.  Phalanges 
may  have  to  be  excised  or  fingers  amputated,  in  consequence  of  ill  effects 
of  old  whitlow.  During  convalescence,  if  contraction  threatens,  place 
finger  on  a  splint.  Stiffiiess  of  hand  may  persist  for  a  very  long  time,  and 
be  eventually  removed  by  passive  exercise,  frictions,  etc. 

Wounds. — Classification. — (1)  Incised,  (2)  lacerated,  (3)  contused,  (4) 
punctured,  (5)  poisoned.  Wounds  are  also  either  open  or  "  subcutaneous." 
1.  Simple  Incised. — Its  characters  are  clean  edges,  freedom  from  bruise  or 
laceration  and  from  poisonous  matters,  at  least  when  first  inflicted.  2. 
Lacerated. — Its  edges  are  usually  irregular,  and  frequently  more  or  less 
contused.  Comparatively  small  tendency  to  bleed.  3.  Contused. — Has 
bruised  edges;  is  usually  also  "lacerated."  4.  Punctured. — E.g.,  a  bayo- 
net stab,  generally  narrow  and  deep.  When  caused  by  gunshot,  its  walls 
are  bruised.  5.  Poisoned  wounds  are  such  as  snake-bites  and  dissection- 
wounds.  In  subcutaneous  wounds  the  aperture  in  the  skin  is  small  com- 
pared to  the  incision  beneath  it,  e.g.,  in  "tenotomy." 

Pathology. — Process  of  repair,  etc.  (compare  with  Inflammation,  quod 
vide). — When  a  simple  incised  wound  is  inflicted,  nature  first  checks 
hemorrhage  by  closing  the  ends  of  the  divided  vessels  in  the  same  man- 
ner described  under  Hemorrhage,  i.e.,  by  coagulation  and  contraction.  At 
the  same  time  there  is  usually  a  thin  clot  formed  between  the  two  surfaces 
of  the  wound.  In  consequence  of  the  blood  being  unable  to  find  its  way 
through  the  divided  vessels,  there  is  congestion  of  the  vessels  about  the 
wound  ;  a^d  the  congestion  of  the  neighboring  parts,  caused  by  the  blood 
pressing  through  the  nearest  uninjured  channels,  is  called  "collateral  flux- 
ion." In  this  way  is  produced  the  narrow  line  of  redness  around  a  fresh 
wound.  The  course  of  events  after  this  is  determined  by  whether  the 
wound  is  to  heal  by  the  first  intention  (primary  union),  or  by  granulation. 
First  Intention. — There  is  a  great  accumulation  of  white  corpuscles,  both 
inside  and  outside  the  blood-vessels  near  the  wound.  These  leucocytes 
permeate  the  clot,  if  there  be  one,  cause  its  liquefaction  and  absorption, 
and  take  its  place.  At  the  same  time,  the  edges  of  the  wound  are  them- 
selves to  some  extent  dissolved  and  replaced  in  the  same  manner.  The 
leucocytes  pass  gradually  through  an  oval  into  a  spindle  shape.  These 
spindle- cells  form,  partly  of  themselves  and  partly  of  the  intercellular 
liquid  substance  in  which  they  lie,  fibres  of  connective  tissue,  thus  tying 
the  two  sides  of  the  wound  together.  At  the  same  time,  new  cajDillaries 
are  formed,  which  bridge  across  the  wound,  allow  blood  once  more  to  flow 
in  its  old  course,  and  thus  relieve  the  collateral  fluxion.  At  this  stage  the 
scar  grows  redder,  and  its  surrounding  edges  paler.  The  new  capillaries 
are  developed  in  two  ways  :  (1)  by  loops  which  grow  out  fi'om  the  vessels 
divided  by  the  wound  ;  (2)  by  certain  rows  of  spindle-cells  which  develop 
into  capillaries.  At  a  later  stage,  the  new  fibrous  "  cicatricial "  tissue  con- 
18 


274  WOUNDS. 

tracts,  becomes  "  drier,"  i.e.,  less  succulent,  and,  in  contracting,  obliterates 
many  of  the  new  capillaries.  The  cicatrix  becomes,  therefore,  smaller  and 
paler.  Of  course,  after  healing  by  the  first  intention,  it  is  merely  linear 
at  first ;  but  in  a  short  time  it  may  defy  detection  altogether.  So  rapidly 
does  this  disappearance  take  place  in  some  cases  that  pathologists  have 
described  what  they  call  "immediate  union"  or  "primary  adhesion," 
meaning,  presumably,  a  perfectly  simple  cohesion  hke  that  of  one  piece  of 
melted  seaUng-wax  with  another,  and  without  further  interstitial  changes. 
Granulation. — The  process  of  healing  when  raw  surfaces  cannot  be 
brought  into  apposition,  and  unfortunately  also  in  some  cases  where  they 
can.  The  microscopic  anatomy  of  this  process  differs  from  that  of  "  pri- 
mary union,"  in  that  (1)  the  accumulation  of  leucocytes  forms,  on  the  sur- 
faces of  the  wound,  small  elevations  called  granulations  ;  (2)  much  of  the 
waste  tissues  and  superfluous  corpuscles,  which  would  be  absorbed  or 
profitably  used  in  healing  by  the  first  intention,  are,  in  the  case  of  healing 
by  granulation,  cast  off  as  piis  ;  (3)  the  new  capillai'ies  cannot  extend  from 
one  edge  of  the  wound  to  the  other,  because  they  are  too  much  separated 
either  by  distance  or  by  some  other  obstruction,  e.g.,  a  foreign  body  or 
excessive  clot ;  (4)  a  much  larger  production  of  epidermis  is  required  to 
cover  the  surface  of  the  wound.  The  resulting  scar  is  larger,  coarser,  and 
much  more  prone  to  mischievous  contraction.  The  new  epidermis  is  de- 
veloped from  the  most  superficial  layer  of  corpuscles  in  the  granulations  ; 
but  it  appears  concentrically  from  the  epidermis  at  the  edge  of  the  wound, 
or  else  spreads  from  islets  of  old  epidermis  left  by  nature  or  placed  by 
art  on  the  area  of  the  wound.  {See  Skin-Gbatting.)  Pus-corpuscles  are 
identical  with  leucocytes,  but  often  contain  several  nuclei,  indicating  a 
tendency  to  multiply  by  division.  Connective  tissue,  epidermis,  epithe- 
lium, bone,  and  even  nerve  are  reproduced  perfectly  (the  last  only  to  a 
limited  extent) .  Muscles  are  only  repaired  by  development  of  connective 
tissue.  Lacerated  and  even  contused  wounds  usually  fail  to  heal  by  the 
first  intention.  The  latter,  especially,  are  liable  to  slough  at  the  edges, 
and  both  tend  to  suppurate  freely.  Much  depends  on  the  conditions  of 
each  case,  e.g.,  on  situation  of  wound,  on  state  of  patient's  viscera,  and  on 
treatment.  Punctured  wounds  usually  heal  by  first  intention,  except 
when  also  contused,  as  they  are  in  gunshot  wounds.  Five  methods  of 
healing  have  been  recognized,  viz.:  (1)  primary  adhesion  ;  (2)  first  inten- 
tion (or  primary  union)  ;  (3)  granulation  (or  second  intention)  ;  (4)  union 
of  two  opposed  surfaces,  each  covered  with  granulations  (third  intention) ; 
(5)  scabbing.  Method  4  combines,  in  succession,  the  processes  of  3  and 
2  ;  5  is  probably  similar  to  3  ;  only,  such  waste-products  as  there  are,  dry 
up  into  a  scab,  being  of  very  small  amount. 

Healing  by  Organization  of  Clot  is  exactly  similar  in  nature  to  healing  by 
the  first  intention,  in  which,  indeed,  a  thin  clot  generally  does  exist  and 
becomes  organized.      A  curious  phenomenon  is,  that  if  any  clot  project 


WOUNDS.  275 

beyond  the  level  of  the  general  surface,  the  new  epidermis  cuts  off  the 
projecting  part,  healing  only  over  the  remainder.  Organization  of  clot  is 
beautifully  seen  after  antiseptic  osteotomy,  and  is  well  described  by  Mc- 
Ewen  in  his  book  on  that  subject.  Lister  rightly  holds  that  the  frequency 
of  this  process  under  antiseptic  treatment  is  a  strong  proof  of  the  sound- 
ness of  his  doctrines. 

Consequences  of  a  wound  are  (1)  pain,  (2)  hemorrhage,  (3)  displace- 
ment, (4)  loss  of  function,  (5)  shock.  Pain  of  dividing  skin,  tense  fascia, 
and  bone  comparatively  great.  {See  Hemorrhage  for  separate  notice.) 
Wounds  by  laceration,  crushing,  and  cauterization  usually  cause  little, 
often  no  hemorrhage.  Displacement  is  usually  a  consequence  of  retraction. 
Not  only  muscles,  but  mere  fibrous  structures  retract,  by  virtue  of  their 
elastic  constituents.  Loss  of  function  varies  in  extent  from  stiffness,  the 
result  of  tenderness,  up  to  death.  (See  separate  notice  for  Shock.)  Re- 
traction is  greatest  in  the  direction  of  the  length  of  a  limb,  and  in  the 
muscles  as  compared  with  the  skin,  etc.  Amount  of  pain  varies  with 
character,  and  even  with  occupation  of  j)atient.  Of  course,  loss  of  function 
and  displacement  may  amount  to  permanent  paralysis  and  deformities.  It 
is  when  the  surgeon  is  about  to  inflict  wounds  [i.e.,  operate)  that  he  has 
most  to  consider  the  above-mentioned  "  consequences."  In  treating  ac- 
cidental wounds,  the  "  consequences  "  are  generally  only  too  manifest. 

Prognosis  depends  on  (1)  locality,  (2)  extent,  (3)  health  of  patient, 
especially  state  of  kidneys  and  lungs,  (4)  age,  (5)  habits,  (6)  surroundings, 

(7)  character,  i.e.,  whether  incised  or  lacerated  or  poisoned  or  otherwise, 

(8)  treatment.  There  are  also  other  conditions  less  generally  active,  e.g., 
i*ace,  which  also  may  be  secondary  to  such  influences  as  habits.  That  wiry 
countrymen  are  much  more  hopeful  subjects  than  fat,  flabby  townsmen,  is 
an  example  of  the  action  of  "  habits  "  and  "  health."  Wounds  of  the  up- 
per do  better  than  those  of  the  lower  extremity,  especially  as  age  advances. 
Generally,  youth  is  a  great  advantage  ;  but  infants  bear  hemorrhage 
badly.     There  is  no  more  unfavorable  habit  than  habitual  drinking. 

Treatment. — Lidications  are  :  (1)  to  check  hemorrhage,  (2)  to  remove 
shock,  if  very  severe,  (3)  to  remove  foreign  bodies  and  to  cleanse,  (4)  to 
adjust,  (5)  to  dress,  (6)  splints,  position,  etc.  (1  and  2  vide  Hemorrhage 
and  Shock.)  8.  Use  of  hot  water,  cold  water,  sponges,  camel's  hair  brushes?, 
forceps,  fingers,  etc.,  according  to  peculiarities  of  each  case.  Gentleness 
is  imperatively  required.  4.  In  adjusting,  avoid  tension.  Arrangement  of 
joints,  etc.,  so  as  to  relax  parts  divided  :  e.g.,  after  accidental  division  of 
tendo  Achillis,  foot  should  be  extended  and  leg  flexed.  5.  Dressings  : 
prime  objects  are,  firstly,  to  keep  the  divided  parts  in  proper  position  ; 
secondly,  to  prevent  local  and  general  complications  which  may  interfere 
with  healing  and  even  endanger  life.  First  object  is  fulfilled  by  use  of 
sutures,  strapping,  pads,  splints  and  position  ;  of  course,  all  this  array  of 
means  is  not  used  in  every  case.    Second  object  requires  precautions  to  be 


276  WOUNDS. 

taken  against  (1)  exposure  to  draughts  of  cold  air,  (2)  painful  movements 
and  positions,  (3)  septic  influences.  Changes  of  dressing  should  be  quickly 
effected,  and  windows  and  doors  closed  during  the  process.  Pain  is  pre- 
vented by  careful  adjustment  of  dressing,  of  splints,  of  position  (especially 
by  elevation  and  flexion),  by  use  of  swing-cradles,  of  cushions,  etc.  Opiates 
sometimes  desirable,  especially  morphia  subcutaneously.  Septic  influences  : 
their  avoidance  can  probably  be  thoroughly  secured  in  only  one  way,  viz., 
by  preventing  the  access  of  liviug  germs  to  the  wound.  But  much  good 
may  be  done  by  removing,  as  fast  as  they  collect,  all  discharges  which  can 
form  a  nidus  for  these  germs.  The  former  end  is  most  surely  secured 
by  the  antiseptic  system  rigorously  applied.  The  latter  aim  can  be  more 
or  less  successfully  attained  by  several  means.  Lister's  antiseptic  sys- 
tem, though  indirectly  {e.g.,  by  expediting  cure)  economical,  is  directly 
expensive,  especially  when  the  surgeon  does  not  habitually  employ  it,  and 
in  the  case  of  very  large  operation-wounds,  e.g.,  amputations  of  the  thigh. 
In  these  cases  immense  quantities  of  expensive  dressings  have  to  be 
changed,  often  daily,  because  of  the  great  discharge.  As,  also,  no  antisep- 
tic system  can  provide  against  all  the  dangers  of  wounds,  it  is  not  sur- 
prising that  a  surgeon,  after  losing  a  case  or  two  dressed  with  thorough 
antiseptic  precautious,  should  be  disjDosed  to  return  to  more  familar 
methods,  upon  which,  in  past  times,  his  fortune  may  have  smiled  more 
favorably.  In  the  case  of  moderate-sized  wounds,  Lister's  antiseptic  system 
is  simply  perfect,  and  almost  proof  against  ordinary  carelessness,  ignorance, 
and  stupidity.  On  the  other  hand,  "  open  treatment "  and  oakum  dress- 
ings are  free  from  the  objections  which  may  be  lu'ged  against  Lister's  an- 
tiseptic system,  in  the  case  of  great  amputations.  They  are  very  cheap 
and  simple.  They  doubtless  both  act  by  gaining  the  second  end  above 
mentioned,  viz.,  the  removal  of  discharge  from  the  wound  as  fast  as  it 
forms,  and,  consequently,  by  depriving  the  septic  germs  of  material  to 
work  upon. 

Pasteur's  experiments  prove  germs  to  be  too  universal  for  the  oakum 
dressings  to  act  otherwise,  as  no  precautions,  such  as  the  carbolic  spray, 
are  usually  taken  whilst  changing  them.  Oakum  dressings  have  these 
superiorities  over  open  treatment,  they  protect  the  wound  from  cold 
draughts,  they  destroy  offensive  smells,  keeping  the  general  air  of  the 
ward  piu-e,  and  they  actively  drain  the  wotmd  by  their  power  of  capillary 
attraction.  What  I  saw  when  house-surgeon  under  Gamgee  at  Bii-ming- 
ham,  convinced  me  that  no  system  of  wound-dressing  could  be  complete 
without  some  provision  for  gentle  and  elastic  compression.  This,  Gamgee 
used  to  secure  with  cotton-wool ;  but  as  soon  as  Martin's  bandages  became 
known  in  England,  I  took  to  completely  covering  with  them  most  of  my 
operation-woimds  which  were  dressed  antiseptically,  and  some  which  were 
not.  I  have  never  seen  a  stump  which  healed  more  rapidly,  or  looked 
better  when  healed,  than  one  which  had  no  dressing  whatever  but  a  rub- 


WOUNDS.  277 

ber  bandage  over  it,  and  a  pad  of  oakum  to  drain  into.  But  in  this  par- 
ticular instance  it  was  not  practicable  to  dress  antiseptically.  The  mode  of 
dressing  used  lately  by  Esmarch,  with  a  success  perhaps  unparalleled,  not 
only  as  regards  general  results,  but  as  regards  individual  cases,  may  be 
described  as  an  instance  of  the  successful  combination  of  autisepticism 
with  gentle  compression.  Next  the  wound  are  placed  pads  soaked  in  iodo- 
form and  absolute  alcohol  (ten  j)er  cent.),  then  an  iodoformed  bandage, 
then  a  large  pillow  of  jute  and  gauze,  then  a  moist  bandage,  and  lastly  an 
elastic  bandage.  Even  after  amputation  of  the  thigh,  this  dressing  seldom 
needs  a  single  renewal.  Healing  takes  place  by  the  first  intention,  not 
even  a  hole  for  the  drainage-tube  being  left ;  for  Esmarch  uses  absorbable 
tubes  of  decalcified  bone.  It  is  most  important  before  applying  such 
dressings  to  check  aU  oozing  of  blood.  ReciuTent  hemorrhage  need 
scarcely  be  feared  at  all.  The  under-bandages  should  be  put  on  as 
lightly  as  possil?le,  and  the  elastic  bandage  should  be  applied  with  great 
care  and  gentleness.  Iodoform,  insufilated,  makes  a  capital  dressing  for 
many  wounds,  e.g.,  lithotomy,  perinseal  section,  ojDerations  near  the  mouth, 
anus,  urethra,  and  the  like.  Other  modes  of  local  treatment,  compara- 
tively rarely  employed,  are  cotton-wool  dressing,  irrigation,  and  immer- 
sion. Poultices  of  hnseed,  or  of  bread,  are  still  in  common  use,  and  are 
certainly  soft,  moist,  hot,  and  comfortable,  and  therefore  possibly  act  fa- 
vorably on  any  local  inflammations  that  may  be  near  the  wound.  Oakum 
(including  the  kinds  termed  "  tenas,"  "  stipium,"  etc.)  is  applied  like  a 
poultice.  Like  every  other  antiseptic  substance,  it  is  somewhat  initating  ; 
therefore  a  narrow  strip  of  pi'otective  should  be  placed  next  the  edges  of 
the  wound.  The  not  uncommon  practice  of  using  lint  soaked  in  cai'bolized 
oil  as  a  protective  is  unreasonable  ;  for  the  lint  obstructs  the  absorptive 
power  of  the  oakum,  whilst  the  carbolic  acid  is  as  irritating  as  the  tar  in 
the  oakum.  Rarely  should  the  wound,  excepting  when  fresh,  be  syringed 
or  washed — it  cannot  be  kept  too  dry.  ( Vide  Antiseptic  Treatment.)  Read 
Gamgee  on  the  "Treatment  of  "Wounds,"  an  authority  on  oakum  and  cot- 
ton-wool dressings,  but  unjust  to  Lister  and  his  methods.  Without  anti- 
septic treatment,  grand  statistical  results  have  been  obtained  by  various 
surgeons  ;  but,  considering  how  many  things  aifect  the  success  of  surgical 
practice,  e.g.,  experience,  observation,  judgment,  resource,  manual  dexter- 
ity, pluck,  and,  perhaps  above  all,  patience  and  enthusiasm,  not  to  men- 
tion endemic  and  epidemic  influences,  it  is  certain  that  "inere  statistics 
prove  little  for  or  against  any  system  of  dressing  wounds,  unless  those  sta- 
tistics extend  over  long  periods  of  time,  different  localities,  and  immense 
numbers  of  cases.  And,  even  then,  they  should  not  be  permitted  to  over- 
rule other  evidence  such  as  presents  itself  to  the  surgeon  who,  in  London 
at  all  events,  watches  any  small  series  of  wounds  in  detail,  of  which  some 
are  treated  antiseptically  and  others  not.  For,  even  the  statistics  of  an 
honest  obseiTer  have  not  really  the  force  of  mathematical  certainty.     Be- 


278  WOUNDS. 

hind  them  is  always  the  human  heart,  whose  truth  is  often  noble,  but  never 
mathematical. 

These  remarks  are  not  uncalled  for.  Repeatedly,  of  late,  have  the  stu- 
dent and  practitioner  been  invited  to  deprive  themselves  and  their  patients 
of  the  safeguards  offered  by  modern  science,  on  the  strength  of  compari- 
son between  the  statistics  of  txoo  places  only.  Such  a  comparison  no  more 
furnishes  an  argument  against  Listerism  than  the  security  of  those  Aca- 
dian farmers,  who  had  "neither  locks  to  their  doors  nor  bars  to  their  win- 
dows," condemns  the  use  of  the  Metropohtan  Police. 

Drainage. — A  necessity  for  all  wounds  where  there  is  likelihood  of  sup- 
pmration  or  serous  discharge.  Effected  by  drainage-tubes  of  rubber,  of 
decalcified  bone  (or,  less  frequently,  of  twisted  wire),  by  strands  of  cat- 
gut or  horse-hair,  or  by  strips  of  gutta-percha.  Desirable  to  consider  how 
to  favor  drainage  in  arranging  direction  of  cuts  and  position  of  wound.  A 
drainage-tube  is  a  foreign  body  which  may  itself  cause  pain  and  irritation. 
As  a  rule,  it  should  be  gently  removed,  squeezed,  and  washed  every  dress- 
ing. It  is  useless  to  try  to  squirt  carbolic  lotion  through  seven  or  eight 
inches  of  a  drainage-tube  riddled  with  holes  and  lying  in  a  wound.  Before 
removing  to  clean,  tie  a  piece  of  silk  to  it.  Leave  this  in  the  wound,  to 
afterward  use  as  guide  for  replacement.     Be  veiy  gentle. 

Very  rarely  do  any  severe  wounds  of  the  soft  parts  alone  require  am,' 
putation.  But  they  may  also  do  so  when  (1)  even  recovery  would  only  be 
with  so  much  deformity  or  loss  of  ftmction  that  the  part  would  be  worse 
than  useless  ;  or  (2)  when  the  injury  is  so  extensive  and  serious  that  gan- 
grene and  death  are  threatened.  Injuries  complicated  with  division  of 
large  arteries,  with  much  contusion,  and  in  the  lower  extremities  of  adult, 
and,  much  more,  of  aged  people,  are  of  this  nature.  No  verbal  rules  can 
do  instead  of  experience  in  deciding  in  such  cases.  Here  even  the  master- 
surgeon  steers  with  perplexity  between  Scylla  and  Charybdis. 


APPENDIX. 


Microscopic  Organism  (Vegetable)  .- 
in  which  they  have  been  found : 


Disease. 

Favus. 

Tinea  tonsurans. 

Sycosis. 

Pityriasis  versicolor. 

Tlirush. 

Concretions  in  the  mouth,  salivary 
ducts,  and  urinary  bladder  (including  all 
carbonate  of  lime  calculi). 

Caries  of  the  teeth. 

Malignant  pustule.  Anthrax  (of  ani- 
mals). 

Malarious  affections. 
Typhoid. 
Typhus. 
Leprosy. 

The  Septic  processes :  septicaemia, 
pyaemia,  progressive  suppurations,  hospital 
gangrene,  diphtheria,  puerperal  fever. 

Mycosis  septica  (Orth) — a  disease  of 
new-bom  infants. 

Mycosis  of  the  navel. 

Acute  exanthemata  :  variola-vaccina, 
scarlatina,  measles. 

Inflammatory  processes :  endocarditis, 
certain  "  rheumatic "  or  "fibroid"  affec- 
tions of  the  liver  and  kidney,  which  "  lead 
more  especially  to  formation  of  connective 
tissue,  and  not  to  suppuration." 

Croupous  pneumonia :  erysipelas  (al- 
lied to  croupous  pneumonia — Klebs). 

"  Certain  puerperal  processes." 

Mumps. 

Tuberculosis. 
Syphilis. 

Glanders. 


-Table  of  the  chief  diseases 


Organism. 


Achorion  Schonleinii. 
Trichophyton  tonsurans. 
Microsporon  mentagrophytes. 
Microsporon  furfurans. 
Oi'dium  albicans. 

Leptothrix. 


Leptothrix. 

Bacillus  anthracis. 

Bacillus  malarias. 
Bacillus  typhi  abdominalis. 
Bacillus  typhi  exanthematici. 
Bacillus  leprosus. 

Cocco-bacteria    (genus  —  "microspo- 
rina  "). 

Cocco-bacteria. 

Cocco-bacteria. 

Cocco-bacteria    (genus — "  monadiua  " 
of  Klebs). 

Cocco-bacteria  (genus — "  monadina  "). 


Cocco-bacteria  (genus — "  monadina  "). 

Cocco-bacteria  (genus — "monadina  "). 
Cocco-bacteria  (genus — "  monadina  "). 

Cocco-bacteria  (genus — "  monadina"). 
Cocco-bacteria  (variety, "  helicomonas  " 
of  Klebs). 

Cocco-bacteria  (variety, ' '  helicomonas") 


Some  of  the  diseases  in  which,  though  not  hitherto  observed,  it  is  highly 
probable  that  microscopic  organisms  wiU  be  found  are  cholera,  yellow  fever, 
and  madura-foot. 


280  MICROSCOPIC    ORGANISM. 

Methods  of  Studying  these  Organisms. — Higli  power  usually  required. 
Many  micrococci  look  small  even  when  magnified  700  diameters.  Most, 
but  not  all,  resist  the  action  of  acids  and  alkalies,  while  animal  tissues  do 
not.  Staining  fluids  :  hsematoxyhn  and  aniline  dyes,  especially  the  latter. 
Special  illumination  apparatus  :  Abbe's.'  Examination  may  be  made  of 
either  (1)  the  diseased  animal  tissues,  (2)  the  soil,  water,  or  air  in  which 
some  of  the  organisms  unquestionably  flom-ish,  (3)  cultivation-fluids  and 
solids,  or  of  (4)  the  tissues  of  animals  artificially  inoculated.  When  culti- 
vation-fluids are  used  or  animals  inoculated,  conclusiveness  may  be  given 
to  the  experiments  by  separating  the  microscojjic  organisms  fi'om  the 
liquids  in  which  they  he.  This  is  done  in  two  ways — (1)  Chauveau's,  who 
used  the  sediment  deposited  by  vaccine  ;  (2)  filtration  through  porous  clay 
(Klebs);  or  through  gypsum  (Pasteur).  Further,  though  individual  ani- 
mals have  vei-y  simdar  susceptibilities  to  these  organisms,  yet  difierent 
species  are  often  very  unequal  in  this  respect.  Thus  the  hving  animal 
body  can  be  sometimes  used  as  a  filter,  to  separate  even  one  kind  of  minute 
organism  from  another  (Koch),  and  it  is,  of  course,  easy  to  separate  any 
organism  which  infects  the  body  generally  fi'om  one  which  infects  only 
locally. 

Botanical  Position. — The  microscopic  organisms,  not  animal,  which  are 
found  in  animal  bodies  in  infective  diseases  all  belong  to  the  sub-class 
Thallogenas.  In  the  order  hyphomycetae  are  achorion,  trichophyton,  and 
oidium.  In  the  order  algse  is  leptothrix.  In  the  order  schizomycetae  may 
be  distinguished  two  widely  different  forms,  viz.,  bacilli  and  cocco-bacteria. 
The  bacilli  have  been  respectively  named  after  the  diseases  in  which  they 
occur.  {See  above.)  Cocco-bacteria  are  divided  again  into  microsporina 
and  monadina. 

Morphology. —In  bodies  so  minute  there  cannot  be  great  variety  in 
shape.  The  chief  forms  are  delicate  rods  and  granules.  The  former  are 
sometimes  jointed,  and  the  latter  are  frequently  arranged  in  a  chain-like 
series.  When  a  number  of  bacilli  are  joined  end  to  end  a  threaddike  ap- 
pearance results.  Masses  of  organisms  occur  termed  zoogloea.  The  size 
varies  somewhat  according  to  the  species. 

Parts  they  Inhabit. — Chiefly  the  blood-vessels.  But  those  which  are  the 
probable  causes  of  local  diseases  are  found  only  locally.  The  contents 
and,  still  more,  the  walls  of  abscesses.  Ogston  says  they  are  always  to  be 
found  in  acute  abscesses.  Pyfemic  deposits.  The  small  metastatic  de- 
posits of  pyaemia,  puerperal  fever,  etc.,  consist  of  bacteria  ;  and  the  dis- 
covery of  this  (by  Rindfleisch)  was  "  the  first  communication  regarding  the 
occurrence  of  bacteria  in  the  organs  of  those  who  have  died  of  traumatic 
infective  diseases "  (Koch).  Granulations.  Joint-surfaces.  Serous  mem- 
branes.    Diphtheritic  exudations.    Pus.    Renal  glomeruli  and  tubuli.    In- 

'  Made  by  Zeiss. 


MICROSCOPIC    OKGANISM.  281 

deed,  every  organ  or  tissue  where  the  blood  can  penetrate  appears  to  bje 
liable  to  invasion  by  some  septic  organism  or  another.  The  monadini 
are  actively  movable,  and  penetrate  the  cells,  causing  considerable  swellr 
ing  of  them. 

How  no  THE  Organisms  entee  the  Body,  and  Whence  do  they  Come  ? — 
They  do  not  exist  normally  in  the  healthy  body.  The  best  observers,  those 
who  have  added  most  positive  information  to  our  knowledge  of  minute 
anatomy,  have  been  quite  unable  to  find  them  herein.  The  same  class  are 
practically  unanimous  in  rejecting  the  idea  of  spontaneous  generation. 
Many  of  the  organisms  enter  seldom  or  never  except  through  wounds  or 
slight  abrasions,  scratches  or  punctures.  Others  readily  cling  to  and 
grow  into  the  cells  of  mucous  membranes.  Possibly  some  may  have  the 
power  of  piercing  skin,  or  at  all  events  the  skin  of  a  person  not  in  perfect 
health.  The  organisms  sometimes  pass  from  one  animal  to  another  by 
contact  with  secretions  or  excretions,  or,  in  a  few  instances  pei'haps, 
through  the  air.  Some  of  the  organisms  exist  constantly  in  certain  locali- 
ties in  the  air,  the  water,  or  the  soil.  Some  cHng  to  certain  buildings, 
perhaps  to  the  walls,  floors,  ceilings,  or  furniture. 

Do  the  Microscopic  Organisms  cause  the  Diseases,  or  are  they  vierely  acci- 
dental concomitants,  "parasites  of  the  diseases,"  so  to  speak? — To  answer  the 
first  part  of  this  question  positively  in  the  affirmative,  it  would  be  necessary 
to  demonstrate  that  (1)  the  organisms  exist  in  every  case  of  each  disease  ; 
(2)  that  they  exist  also  in  sufficient  numbers  and  in  the  proper  localities  to 
cause  the  phenomena  of  the  disease  ;  (3)  that  when  transferred  success- 
fully and  purely  from  one  animal  body  to  another  of  the  same  species  they 
reproduce  the  disease.  Moreover,  it  would  be  very  desirable  to  show  that 
the  organisms  of  different  diseases  have  themselves  different  morphologi- 
cal peculiarities.  The  difficulties  of  fulfilling  all  these  requirements  are  im- 
mense ;  but  they  have  been  overcome  in  the  case  of  a  sufficient  number  of 
distinct  diseases  to  encourage  hope  that  ultimate  success  will  attend  the 
investigation  of  the  others.  Finally,  it  should  be  noticed  that  Koch,  hav- 
ing produced  pyaemia  in  mice,  found  that  the  micrococci  adhered  to  the 
red  corpuscles,  and  that  the  red  corpuscles  thus  affected  tended  to  crowd 
together  in  the  capillaries.  The  ultimkte  i*esult  of  this  was  thrombosis. 
This,  perhaps,  explains  the  occurrence  of  "  metastatic "  abscesses  in 
pyemia. 

Many  substances  are  fatal  to  every  kind  of  bacteria.  Such  are  carboKc 
acid,  oil  of  eucalyptus,  salicylic  acid,  and  iodoform.  There  are  sti'ong 
reasons  for  believing  that  certain  substances  are  especially  destructive  to 
particular  species,  e.g.,  quinine  to  bacillus  malarise.  Koch  says  that 
"Eidam  came  to  the  conclusion  that«different  foiTQS  of  bacteria  require 
diffei-ent  conditions  of  nutriment,  and  that  they  behave  differently  toward 
physical  and  chemical  influences."  But  it  is  not  too  much  to  hojie  that  the 
mai'vellous  resources  of  organic  chemistry  may  soon  prove  to  us  that  in 


282  OSTEOTOMY. 

science,  as  in  law,  there  is  "no  wrong  without  a  remedy."  The  discoveries 
of  Pasteur,  Chauveau,  and  Toussaint  suggest  the  possibility  of  apply  in  o- 
the  principle  of  inoculation  as  a  prophylactic  against  many,  if  not  all,  spe- 
cific organisms.  Pasteur  has  shown  that  by  the  action  of  heat  and  oxygen, 
organisms,  deadly  to  certain  animals,  may  be  so  modified  that,  while  pre- 
serving the  power  of  infection,  they  can  infect  only  mildly,  and  yet  protect 
the  inoculated  animal  against  future  infection  by  more  active  organisms 
of  the  same  species. 

In  constructing  the  above,  unfortunately,  very  imperfect  account  of 
the  present  state  of  knowledge  concerning  a  subject  of  absorbing  interest 
and  vast  importance,  I  have  been  chiefly  indebted  to  Koch,  on  the  "Etiol- 
ogy of  Traumatic  Infective  Diseases,"  translated  for  the  New  Sj'denham 
Society  by  Cheyne,  and  to  the  addresses  of  Pasteur  and  Klebs  at  the  In- 
ternational Congress,  1881,  In  these  may  be  found  the  names  of  the 
numerous  workers  who  have  discovered  what  is  at  present  known  of  the 
subject. 

Charcot's  Joint  Disease. — Preceded  by  the  "lightning  pains,"  char- 
acteristic of  tabes  dorsalis  or  locomotor  ataxy.  The  limb  near  the  affected 
joint  sometimes  swells  quickly  and  extensively,  after  some  time  returning 
again  to  its  normal  size.  Spontaneous  dislocations.  Fractures  caused  by 
gentle  movements.  Accompanying  signs  of  locomotor  ataxy,  e.g.,  more  or 
less  inco-ordination  of  movements  and  loss  of  muscular  sense.  "The 
very  rapid  and  extreme  wearing  away  of  the  articular  extremities  of  the 
bones  is  the  principal  character  which,  from  an  anatomico-pathological 
point  of  view,  distinguishes  the  arthropathies  of  ataxia  from  common 
rheumatic  arthritis  {arthrite  seche)."  There  is  also  little  or  no  formation 
of  osteophytes.  Excellent  model  and  specimens  in  St.  Thomas's  Hospital 
Museum. 

Osteotomy. — A  term  now  practically  confined  to  the  division  of  bone 
for  deformity,  with,  at  most,  the  removal  of  a  wedge-shaped  piece. 

Instruments. — Saws,  osteotomes,  and  chisels.  Saws  are  very  narrow, 
and  either  blades  or  chains.  Osteotomes  resemble  chisels,  but  they  are 
bevelled  on  both  sui'faces,  while  the  chisel  proper  is  bevelled  only  on  one. 
The  temper  of  the  steel  and  angle' of  the  bevel  are  of  high  importance  in 
the  case  of  osteotomes  and  chisels.  ImprojDer  instruments  would  easily 
cause  fatal  results,  or,  at  aU  events,  splintering  of  bone,  great  shock,  per- 
haps failure  to  obtain  the  object  aimed  at,  and  occasionally  a  piece  of  the 
chisel  left  in  the  bone.  A  proper  osteotome  can  be  driven  by  a  mallet 
through  the  femur  of  an  ox  without  splintering  the  latter  or  damaging 
itself.  Never  use  a  hammer.  Osteotomes  are  used  for  simple  division. 
Chisels  are  entirely  unfit  for  this  purpose,  except  in  the  case  of  very  small 
bones,  and  shoiild  be  z-eserved  for  remo\'ing  wedge-shaped  pieces.  Place 
limb  on  a  sand-piUow  (moistened  just  before  operation  and  covered  with 
waterproof ). 


>  OSTEOTOMY.  2S3 

Management  of  the  Saw. — Adams'  is  commonly  used.  It  has  a  shank 
and  is  usually  pointed.  The  soft  structures  are  incised  with  a  long  tenot- 
omy-knife  down  to  the  bone,  and  the  periosteum  is  cut  with  the  same 
knife.  The  orifice  of  the  incision  is  usually  only  half  an  inch  long,  or 
even  less.  The  knife  being  withdrawn,  the  saw  is  passed  into  the  tunnel 
just  prepared  for  it  and  its  cutting  edge  turned  to  the  bone.  The  saw  is 
generally  withdrawn  when  two-thirds  of  the  bone  are  divided,  then  the 
remainder  is  broken. 

Use  of  the  Osteotome. — Insert  a  scalpel  right  down  to  the  bone  at  the 
place  to  be  divided.  Wait  two  or  three  seconds,  to  give  the  muscles  pen- 
etrated time  to  quiet,  then  complete  incision.  Size  of  incision  should  at 
first  be  large  enough  to  admit  finger.  As  operator  gains  experience  he 
will  venture  safely  to  dispense  with  this  and  pass  in  the  osteotome  alone. 
Incise  in  line  with  the  bone  to  be  divided.  Botate  osteotome  when  it 
reaches  the  bone.  Do  this  lightly  so  as  not  to  damage  the  periosteum. 
Hold  handle  of  osteotome  firmly  in  left  hand,  with  ulnar  border  of  that 
hand  against  the  skin  of  the  limb.  The  direction  and  management  of  the 
instrument  vary  with  the  site  of  operation.  As  a  rule  cut  away  from 
large  arteries  and  divide  the  hardest  part  of  the  bone  first.  When  remov- 
ing the  osteotome,  keep  the  thumb  and  first  two  fingers  closed  upon  it, 
and  gradually  work  it  out  by  alternate  contractions  and  relaxations  of  the 
other  fingers.  When  two-thirds  of  the  bone  are  divided  the  rest  can  usu- 
ally be  broken. 

In  using  the  chisel  turn  the  bevelled  side  toward  the  wedge.  If  the 
"wedge  is  to  be  thick,  cut  a  thin  wedge  first  and  chip  away  other  j)ieces 
fi'om  each  side  of  the  gap. 

Never  use  either  osteotome  or  chisel  as  a  lever  to  break  bone.  Keep 
saws,  osteotomes,  and  chisels  bright  and  free  from  rust,  or  they  clean  them- 
selves in  the  bone.  Check  all  hemorrhage  before  dressing.  When  both 
limbs  are  osteotomized,  the  first  wound  can  be  compressed  with  an  anti- 
septic sj^onge  and  gauze  bandage  while  the  other  is  being  operated  on. 
Operate  strictly  antiseptically.  Cut  away  any  projecting  cellular  tissue, 
as  it  delays  cicatrization.  Use  no  drainage-tube  unless  some  accidental 
circumstance  occurring  during  the  operation  leads  you  to  expect  sup- 
puration. Healing  usually  takes  place  by  organization  of  blood-clot 
(see  Wounds),  but  by  granulation  where  cellular  tissue  is  exposed  uncov- 
ered by  blood. 

After-treatment.  — Take  temperature  morning  and  evening.  A  tempera- 
ture of  101°  demands  inquiiy.  It  may  arise  from  some  quite  accidental 
complication  independent  of  the  operation,  or  from  a  tight  bandage,  or 
from  an  accidental  sore-throat,  or  trivial  ailment.  If  it  cannot  be  thus  ac- 
counted for,  expose  and  examine  the  wound.  After  osteotomy  of  the 
lower  limbs,  unless  the  divided  bone  is  supported  in  a  firm  plaster  case, 
some  contrivance  is  useful  to  facilitate  defecation,  e.g.,  a  mattress  with  a 


284  OSTEOTOMY. 

movable  central  piece,  or  my  stretcher.  Immediately  after  the  bone  has 
been  divided  it  should  at  once  be  put  into  the  position  ultimately  re- 
quired. After  osteotomy  of  the  limbs,  attend  during  the  first  twenty-four 
and  forty-eight  hours  very  carefully  to  the  state  of  the  toes  or  fingers,  as 
the  case  may  be.  They  should  be  free  from  numbness  and  obstructed 
circulation.  Permeation  of  discharge  should  be  looked  for  from  day  to 
day,  though  it  seldom  occurs  after  the  first  two  days.  So  long  as  it  is 
absent  the  dressing  does  not  need  removal. 

Genu-valgum,  Osteotomy  for. — Place  of  Incision  for  IIcEicen's  Opera- 
tion.— On  the  inner  side  of  the  limb,  at  a  point  where  the  two  following 
lines  bisect  one  another  :  a  Hne  drawn  a  finger's  breadth  above  the  level 
of  tlie  upper  border  of  the  external  condyle,  and  a  hne  drawn  parallel  to 
and  half-an-inch  in  front  of  the  tendon  of  the  addiictor  magnus.  Manage- 
ment of  Osteotome. — To  begin  with,  place  it  against  posterior  part  of  inner 
border  of  femur  and  cut  from  behind,  forward  and  outward,  away  from 
femoral  arter^'.  Remember  that,  just  above  the  condyles,  the  outer  bor- 
der of  the  femur  is  thicker  than  the  inner. 

Place  of  Incision  in  Cliiene's  Operation. — "An  incision  two  to  three 
inches  in  length  is  made  over  the  tubercle  "  (that  of  the  adductor  magnus) 
"and  is  carried  upward  for  a  sufficient  distance." 

The  Wedge. — "The  long  axis  of  the  wedge  runs  downward  and  out- 
ward toward  the  notch  between  the  condyles." 

Grasp  the  tibia  at  its  lower  extremity,  and  by  pressure  inward  bend  the 
neck  of  the  bone  attaching  the  condyle  to  the  femur.  {See  Edinburgh 
Medical  Journal,  1878.) 

Ogston's  Operation  for  Genu-valgum. — If  the  genu-valgum  be  severe, 
operate  with  the  knee  bent,  otherwise  with  the  knee  extended.  A  tenot- 
omy-knife  is  inserted  at  a  point  as  far  back  as  the  level  of  the  internal  con- 
dyloid ridge,  and  about  four  inches  above  the  most  prominent  point  of  the 
internal  condyle.  It  is  passed  downward,  outward,  and  forward,  to  the 
notch  between  the  two  condyles,  until  the  point  can  be  felt  projecting  in 
front  of  that  notch.  Before  withdrawing  it,  the  periosteum  and  cartilage 
are  incised.  An  Adams'  saw  is  now  passed  in,  and  the  internal  condyle 
sawn  two-thirds  off.  Now,  extending  the  limb  (if  it  has  been  flexed  hither- 
to), and  using  the  tibia  as  a  lever,  vdth  the  operator's  knee  as  a  fulcrum, 
the  limb  should  be  bent  inward  till  the  internal  condyle  cracks  off  and 
slips  upward.  With  splints  and  pads  place  and  keep  the  limb  straight  till 
union  has  taken  place.  Commence  passive  motion  about  the  end  of  the 
tliu'd  week.  Of  course,  use  strict  antiseptic  treatment.  {See  Edinburgh 
Medical  Journal,  March,  1877.) 

Dressings,  etc.,  of  Osteotomies  for  Genu-valgum. — See  general  remarks 
above.  Well  and  judiciously  padded  box-splints  are  commonly  used.  But^ 
as  few  or  no  changes  of  dressing  are  usually  required,  the  limb  can  be 
once  for  all  fixed  in  a  moulded  case  of  plaster-of-Paris  or  similar  material 


OVARIES.       (by   MR.    DORAN.)  285 

Osteotomy  fob  Ankylosis  of  Hip  in  a  Bad  Position. — If  there  be  a  good 
neck  to  the  femur,  in  other  words,  if  the  great  trochanter  appear  to  be  set 
far  enough  away  from  the  os  innominatum,  divide  the  neck  of  the  femur. 
Otherwise  operate  below  the  great  trochanter. 

Dividon  of  Neck  of  Femur  with  an  Osteotome.  — Bisect  a  hne  between 
the  ant.  sup.  spine  of  ilium  and  the  ant.  sup.  angle  of  the  gi-eat  trochanter. 
At  the  point  thus  found  pass  in  a  sharp-pointed  steel  du-ector  backward, 
inward,  and  a  little  downward  till  it  stops  at  the  neck  of  the  femui-.  Along 
this  director  pass  a  scalpel  down  to  the  bone  ;  first  cut  toward  the  tro- 
chanter, then,  rotating  the  du-ector  and  reinserting  the  scalpel,  cut  toward 
the  ant.  sup.  spine.  The  incision  shovJd  just  admit  the  forefinger.  Do 
not  withdraw  the  director  till  the  osteotome  is  inserted.  Eotate  osteotome 
BO  as  to  bring  it  across  the  neck  of  the  femur,  cut  nearly  through  and 
break  the  rest. 

Division  of  Neck  of  Femur  with  Saw  (Adams'  operation). — W.  Adams 
passes  in  a  long  tenotomy  knife  "a  little  above  the  top  of  the  great  tro- 
chanter," and  straight  down  to  the  neck  of  the  femur.  He  divides  the  mus- 
cles and  "  opens  the  capsular  hgament  freely."  A  naiTow-bladed  saw  is 
passed  into  the  wound  and  across  the  front  of  the  neck  of  the  femur,  with 
its  flat  side  against  the  bone.  It  is  now  turned  on  edge  and  the  division 
accomplished. 

Extension  by  weight,  and  without  any  splint,  after  osteotomy  of  the 
neck  of  the  femur,  is  to  be  preferred.  Sometimes  a  second  weight  puUing 
outward  from  the  upper  third  of  the  thigh  adds  to  comfort.  When  it  is 
used  a  felt  splint  should  be  moiilded  to  the  inner  side  of  the  thigh  to 
distribute  the  pressure.  Keep  the  foot  perpendicular,  or  even  a  httle  in- 
verted. 

Removal  of  Wedge  of  Bone  for  Cukvatuee  of  Tibia. — Use  a  chisel. 
Make  a  single  incision,  the  loose  skin  will  permit  this  to  be  moved  up  and 
down.  The  wedge  need  not  go  more  than  three-fourths  through  the  bone. 
Supposing  it  to  be  made  at  the  apex  of  the  angle  of  curvature,  its  upper 
sui-face  should  be  at  right  angles  to  the  border  of  the  tibia  above,  and  its 
lower  sirrface  at  right  angles  to  the  border  of  the  tibia  below.  WTien  ad- 
justing the  bony  surfaces  avoid  nipping  muscle.  The  fibula  can  either  be 
broken  or  divided  through  a  separate  incision  of  the  soft  parts.  See  gen- 
eral directions  above. 

Every  commencing  osteotomist  should  study  McEwen's  book. 

Ovaries.' — Chief  affections  :  inflammation,  acute  and  chronic  ;  cystic 
disease  ;  solid  tumors. 

Ovary,  Acute  Inflamjution  of.— Causes. — Gonorrhoea,  sexual  excesses, 
exposure  to   cold,   etc.      Symptoms. — Severe  pains  in  one  or  both  iliac 

'  Contributed  by  Mr.  Alban  Doran,  Assistant  Surgeon  to  the  Samaritan  Hos- 
pital. 


286  OVARIES.       (by   MR.    DORAN.) 

fossae,  radiating  to  loins.  By  pressing  the  left  hand  on  the  iHac  fossa,  and 
introducing  two  fingers  of  the  right  hand  into  the  vagina,  pressing  up- 
ward, the  ovary  may  be  felt  between  the  right  and  left-hand  finger — it 
will  be  distinctly  swollen,  and  very  tender.  Treatment. — ^Absolute  rest. 
Leeches  and  poulticing  to  iliac  fossa. 

OvAEY,  Chkoxic  Inflammation  of. — Very  insidious,  and  often  begins 
gradually  ;  not  always  preceded  by  acute  symptoms,  may  end  in  cirrhotic 
changes  ;  and  is  sometimes  associated  with  persistent  dysmenon-hoea  so 
intolerable  that  both  ovaries,  when  thus  afifected,  have  been  of  late  years 
frequently  removed,  without  always  relieving  the  symptoms.  Fixed  pain 
in  ihac  fossae,  and  detection  of  swollen  ovary  the  chief  signs  of  the  dis- 
ease, local  complications  infinite.  Treatment. — Blisters,  rest  during  period  ; 
observe  closely  the  condition  of  surrounding  riscera,  and  treat  accord- 
ingly. 

OvAKY,  Cystic  Dise.\se  of. — Pathology'-  not  yet  absolutely  settled.  Cysts 
that  are  evidently  developed  from  enlargement  and  non-rupture  of  the 
Graafian  vesicles  seldom  appear  to  form  a  large  tumor.  Commonest  form 
is  the  multilocular  cyst,  originating  in  morbid  changes  in  the  stroma  and 
its  vessels,  and  containing  glairy  fluid  more  or  less  colored  ;  contents  may 
be  partly  sohd.  Another  type  is  the  2^arovarian  cyst,  unilocular  or  nearly 
BO,  and  containing  clear,  watery,  transparent  fluid.  A  third  is  multilocular, 
and  contains  exuberant  papiUary  growths  in  its  cavities.  This  also  holds 
clear  fluid,  and  like  the  second  kind,  is  believed  to  be  developed  from  ves- 
tigial relics  of  the  Wolffian  body.  Lastly  come  dermoid  cysts,  containing 
hair,  sebaceous  matter,  teeth,  bone,  and  walls  lined  with  skin,  bearing 
complete  glandular  structures. 

Symjitoms. — Gradual  distention  of  abdomen  ;  a  prominent  fluctuating 
tumor  occupies  the  hypogastric,  umbihcal,  and  often  epigastric  regions  of 
the  abdomen,  extending  more  or  less  into  the  flanks.  May  bulge  into 
Douglas's  pouch,  where  it  can  be  felt  from  the  vagina,  or  may  draw  uterus 
high  up  ;  then  it  cannot  be  detected  by  vaginal  examination. 

Diagnosis. — From  ascites :  as  the  patient  lies  supine,  the  bulging  and 
dulness  is  in  the  front  of  the  abdomen  in  cystic  ovarian  disease,  in  the 
flanks  in  ascites  ;  in  the  latter  resonance  is  altered  by  change  of  position, 
but  not  in  the  case  of  ovarian  cyst.  From  cystic  kidney :  in  this  disease 
the  dulness  is  veiy  marked  in  one  flank,  and  seldom  extends  far  across  the 
median  line  to  the  opposite  side  of  the  abdomen.  It  may  push  the  colon 
forward,  which  may  be  detected,  as  a  cord,  or  a  tube  resonant  on  percus- 
sion, in  front  of  it.  From  hydatid  cysts :  when  in  the  liver,  there  is  reso- 
nance in  the  lower  part  of  the  abdomen,  but  abnornal  dulness  to  the  right 
side  above  ;  the  fluctuating  cysts  project  from  the  solid  liver.  WTbien  in 
the  great  omentum,  the  abdomen  becomes  distended,  but  not  prominent 
anteriorly  ;  the  small  fluctuating  cysts  can  be  detected  separately,  feeUng 
on  palpation  hke  potatoes  in  a  sack.     In  all  cases  of  hydatid  disease  tap- 


OVARIES.       (by    MR.    DORAN.)  287 

ping  will  procure  the  characteristic  fliiid.  From,  fibro -cystic  uterine  tumors : 
chiefly  by  introducing  the  sound  into  the  uterus.  If  it  move  very  inti- 
mately with  the  tumor,  that  growth  may  be  uterine,  or  else  an  ovarian  cyst 
with  very  close  connections  with  the  uterus.  The  diagnosis  from  soft  sohd 
growths  must  depend  on  careful  palpation. 

Complications. — Inflammation  of  the  cyst- wall,  indicated  by  sudden  at- 
tacks of  abdominal  pain,  and  generally  causing  adhesions  to  abdominal 
walls,  omentum,  or  viscera.  Suppuration  of  cyst,  indicated  by  rigors. 
Strangulation  of  cyst  by  twisting  on  its  own  pedicle,  so  as  to  obstruct  its 
nutrient  vessels.  If  partial,  this  may  cause  diminution  in  size  of  cyst  from 
atrophy  ;  if  complete,  the  cyst  will  slough,  with  fatal  results  if  not  relieved. 
Rupture  of  cyst,  from  violence  or  from  degeneration  of  its  walls  ;  the  tumor 
gets  suddenly  smaller  and  less  defined,  with  more  or  less  severe  abdominal 
symptoms. 

Treatment. — If  the  patient  be  very  weak,  and  suffer  from  extreme  dis- 
tention, the  tumor  may  be  tapped,  and  the  operation  deferred  for  a  few 
weeks.  It  is  always  right  to  operate,  and  as  early  as  possible,  except 
in  cases  of  cysts  that  appear  to  contain  solid  malignant  growths,  and  are 
at  the  same  time  suspected  of  being  intimately  adherent  to  other  struc- 
tures. 

Ov.\EiOTOMY. — Place  the  patient  on  her  back,  with  shoulders  slightly 
elevated.  Make  an  incision  a  few  inches  long  over  the  linea  alba,  begin- 
ning about  an  inch  below  the  umbilicus.  Bleeding  vessels  are  best  secured 
till  the  end  of  the  operation  by  self-holding  forceps,  which  check  hemor- 
rhage permanently.  When  the  peritoneum  is  divided  and  the  cyst  ex- 
posed, plunge  the  special  trochar  into  the  tumor,  withdrawing  fluid  con- 
tents through  cauula  into  a  pail  or  other  receptacle  under  the  table. 
Break  down  solid  contents  of  cyst  with  hand  introduced  into  the  tumor. 
If  there  be  adhesions  to  parietal  peritoneum,  break  them  down  with  hand, 
and  secure  any  bleeding  vessels  ;  adherent  omentum  must  be  cut  away 
and  the  vessels  secured  ;  pelvic  and  visceral  adhesions  require  gi*eat  cai'e 
in  separation.  Then  place  two  or  three  clean  sponges  into  pelvic  cavity 
and  above  tumor.  Raise  the  flaccid  tumor  out  of  the  wound  ;  the  pedicle 
must  then  be  transfixed  (avoiding  large  veins)  by  a  stout  needle  armed  with 
two  stout  silk  threads.  The  ends  of  each  thread  on  one  side  of  the  pedicle 
must  be  crossed  over  each  other,  then  tie  the  free  ends  round  the  opposite 
sides  of  the  pedicle.  If  the  outer  border  of  the  pedicle  be  very  tense, 
secure  the  ovarian  vessels  separately,  else  they  will  slip.  The  pedicle,  if 
very  broad,  may  require  a  second  transfixion,  the  thi*eads  must  then  be 
crossed  again  on  one  side  as  before.  Next  cut  the  tumor  away  and  drop 
the  pedicle.  Search  for  the  other  ovary,  and  remove  it,  if  it  be  distinctly 
cystic.  Then  take  out  the  sponges,  and  see  if  they  show  that  there  has 
been  fresh  hemorrhage  from  separated  adhesions ;  use  fresh  sponges  to 
mop  up  any  cystic  fluid  or  clots  that  may  have  escaped  into  the  cavity  of 


288  HEREDITAKY    SYPHILIS. 

the  peritoneum.  Eemove  all  forceps  and  sponges,  count  them,  sew  up 
abdominal  wound  with  silk  thread  or  silkworm  gut  threaded  to  a  needle 
at  each  end,  introducing  the  needles  from  the  peritoneal  side,  and  avoid- 
ing the  recti  muscles.  Some  operators  use  the  cautery  instead  of  the 
ligature  for  securing  the  pedicle  ;  the  clamp  is  almost  entirely  discarded. 
Lister's  precautious  valuable  in  this  operation.  In  cases  of  strong  ad- 
hesions, with  exudation  from  peritoneum  after  they  have  been  separated, 
pass  a  glass  drainage-tube  into  Douglas's  pouch  through  the  abdominal 
wound. 

OvAKY,  Solid  Tumoes  of  the. — Fibroma  or  fibromyoma  sometimes  ob- 
served in  the  ovary.  Its  occurrence  there  can  be  understood  now  that  the 
strong  resemblance  of  the  spindle-cells  in  the  stroma  to  uterine  tissue  is 
well  recognized.  Sarcomata  and  carcinomata  fi'om  solid  tumors  distin- 
guished from  uterine  growth  by  their  being  free  from  the  uterus,  as  the 
sound  will  detect.  They  are  nearly  always  accompanied  by  ascites :  the 
health  rapidly  deteriorates.  Treatment. — Fibromata  and  even  malignant 
tumors  may  be  removed  by  ovariotomy.  Abdominal  wound  must  be 
large,  often  extending  above  umbilicus  ;  the  pedicle  is  generally  very  thick 
and  vascular.  Never  operate  on  malignant  growths  when  there  is  much 
ascites  with  large  cells  in  the  fluid,  oedema  of  the  abdominal  walls,  evi- 
dence of  strong  adhesions,  or  marked  cachexia. 

Scarlatina  not  unfrequently  complicates  the  after-course  of  operations 
on  children.  It  appears  to  differ  little  from  ordinary  scarlatina,  provided 
only  natm-e  or  antiseptic  treatment  guards  the  little  patient  from  coinci- 
dent septicaemia.  If  anything,  it  is  less  dangerous  than  ordinary  scarla- 
tina. The  subject  has  been  extensively  treated  of  late  years  in  the  journals 
and  hospital  reports,  and  at  the  Societies,"  by  Messrs.  Marsh,  Howse, 
Owen,  etc. 

Hereditary  Syphilis  (Congenital  Syphilis). — In  hereditary  syphilis 
the  foetus  either  (1)  dies  early  in  utero,  abortion  taking  j)lace,  or  (2)  is 
born  alive  prematurely,  or  (3)  is  born  dead  at  full  term,  or  (4)  is  born  ap- 
parently healthy,  the  disease  manifesting  itself  afterward.  The  more  recent 
the  syphilis  in  the  parents,  the  greater  the  danger  to  the  infant.  In  the 
case  of  syphilis  of  the  placenta  the  fetal  portion  is  much  more  commonly 
affected  than  the  maternal  Gummata  are  found  therein  in  the  form  of 
yellowish  white  tubercles.  Hennig  showed  their  intimate  relation  to  the 
vessels.  The  obliteration  of  the  vessels,  if  extreme,  interferes  with  aera- 
tion of  the  fetal  blood,  thus  producing  death  of  the  foetus  (Frankel,  quoted 
by  Baumler).  Infants  with  congenital  sj^hilis  are  generally  in  appearance 
old,  small,  and  shrivelled.  They  have  snuffles,  i.e.,  nasal  cataiTh,  and  erup- 
tions. These,  usually  papular  or  roseolar,  are  sometimes  bullse,  but  rarely 
pustular,  and  very  rarely  vesicular.     Bullae  (pemphigus  neonatorum  syphi- 


*  Also  at  the  International  Congress,  London,  1881. 


VACCINO-SYPHILIS.  289 

iticus)  occur  especially  on  palms  and  soles.  This  is  a  point  in  diagnosis. 
Mucous  tubercles  at  comers  of  mouth  and  eyes,  in  flexure  of  limbs,  on  neck 
and  behind  ears.  Characteristic  eruptions  are  very  copper-colored.  Stoma- 
titis. Mucous  tubercles  in  mouth,  throat,  and  larynx.  Iritis  sometimes, 
especially  about  fifth  month.  Deafness  occasionally.  Osteo-chondritis. — 
Important  diagnostically,  because  it  is  often  the  only  pathognomonic  symp- 
tom. It  is  caused  by  syphiHs  exclusively.  Affects  chiefly  epiphyses  of  long 
bones — femur,  tibia,  humerus,  etc.,  clavicle,  sternum,  ribs.  Epiphyseal 
cartilages  swell,  and  can  be  felt  projecting  as  would  a  ring  round  the  bone. 
The  swelling  is  usually  smooth.  Little  or  no  pain  or  interference  with 
movement.  Occasionally  causes  ulceration  and  necrosis.  Is  commonly 
symmetrical.  Leaves  no  ill  effects  if  resolution  takes  place  quickly.  Other- 
wise may  permanently  affect  growth  of  hmb.  Period  of  its  occurrence, 
usually  at  birth  or  during  first  month.  For  a  very  full  account  read  Bum- 
sted  and  Taylor.  But  "Wegner,  of  BerHn,  first  described  it.  Sjjleen  is  en- 
larged in  at  least  fifty  per  cent,  of  cases,  and  often  accompanied  by  hyper- 
trophy of  liver  (Gee).  Later  Effects. — About  period  of  second  dentition,  or 
about  puberty  (in  girls  especially),  appear  interstitial  keratitis,  serpiginous 
ulcerations,  eruptions  almost  rupial  in  character,  vilcerations  of  throat  and 
hard  palate,  nodes,  affections  of  viscera ;  and  certain  nervous  affections, 
especially  epilepsy,  chorea,  and  even  paralyses  (Hughhngs  Jackson).  The 
characteristic  signs  present  at  this  period,  besides  the  manifestations  just 
mentioned,  are  certain  relics  of  infantile  syphHis,  viz.,  flattened  nose,  pro- 
jecting forehead,  dull-colored  skin,  lines  about  the  comers  of  the  mouth, 
and  "  Hutchinson's  teeth."  The  peculiarities  of  the  last  are  due  to  stomatitis 
in  infancy  ;  therefore,  if  the  syphilitic  infant  escape  stomatitis,  it  will  es- 
cape teeth  deformity.  The  upper  front  permanent  teeth  are  the  most  pecu- 
liar, the  central  incisors  especially.  These  converge  toward  each  other,  are 
dirty  looking,  imperfectly  covered  with  enamel,  often  small  and  short,  and 
are  either  notched  or  pegged  on  their  cutting  edges.  Prognosis. — Depends 
mainly  on  the  severity  of  the  symptoms.  The  worst  cases  usually  die. 
But  most  infants  and  adolescents  (especially  the  former)  with  inherited 
syphilis  are  strikingly  amenable  to  treatment.  Treatment  is  to  be  con- 
ducted on  exactly  the  same  principles  as  that  of  acquired  syphilis,  q.v. 
Children  readily  take  hyd.  c.  creta,  or  respond  to  mercurial  inunction.  Al- 
ways add  iodide  of  potassium  when  bone  is  affected,  and  in  the  later  mani- 
festations. 

Vaccino-Syphilis. — The  chief  practical  points  connected  with  this 
subject  are  that  (1)  the  child  from  whom  the  lymph  is  taken  should  not 
be  less  than  four  months  old  ;  (2)  the  lymph  first  drawn  from  the  pustule 
should  be  used ;  (3)  it  should  be  clear,  entirely  free  from  any  perceptible 
admixture  of  pus  or  blood  ;  and,  of  course,  (4)  the  appearance  and  history 
of  the  child  and  its  parents  should  be  unimpeachable.  But  Keber,  of 
Dantzig,  has  shown  that  even  clear  vaccine  lymph  contains  pus  and  blood- 
19 


290  TOOTHACHE. 

corpuscles,  and  in  a  small  proportion  of  infants  (5  in  158,  Diday)  congeni- 
tal syphilis  does  not  show  itself  till  later  even  than  the  fourth  month. 
Lymph  from  the  calf  is  much  less  likely  (according  to  some  certain)  to  be 
free  from  any  taint  of  syphilis.  When  syphilis  is  communicated  by  vac- 
cination the  pock  runs  its  normal  course,  and  no  sign  of  specific  infection 
appears  till  about  the  twenty-eighth  day.  Eefer  to  Hutchinson's  "  Illus- 
trations of  Clinical  Surgery,"  fasc.  vi  ;  and  to  Hugh  Thompson,  Glasgow 
Medical  Journal,  1879. 

Toothache  '  is  a  pain  arising  from  a  lesion,  either  within  or  about 
the  region  of  a  tooth.  Causes. — Caries ;  irritation  of  the  pulp  ;  acute  and 
chronic  inflammations  of  the  tooth-pulp  ;  acute  and  chronic  periodontitis  ; 
exostosis  and  necrosis.  Symptoms.  — When  toothache  arises  from  caries, 
the  pain  is  of  a  dull  aching  character,  and  is  treated  by  the  application  of 
creosote,  morphia,  mastiche,  and  various  anodynes,  which  are  inserted 
into  the  cavity  of  the  aifected  tooth,  and  then  in  a  few  days  the  carious 
matter  excavated,  and  metallic  fillings  placed  in  the  tooth.  In  irritation  of 
the  pulp  the  pain  is  the  same  as  in  the  above  affection,  but  is  more  pro- 
longed, and  is  treated  in  the  same  manner.  Toothache  feom  acute  inixam- 
MATioN  OF  THE  PULP  is  recoguized  by  the  pain,  which  is  at  first  confined  to 
the  affected  tooth,  being  of  a  dull  aching  character,  which  soon  becomes 
more  intense  and  lancinating,  and  appears  to  spread  over  entire  side  of 
head  and  face.  Disease  is  almost  always  accompanied  by  caries,  and  may 
run  on  to  suppuration  and  gangrene  of  the  pulp.  Treatment. — In  children 
the  extraction  of  the  offending  tooth  is  generally  called  for ;  but,  in 
adults,  either  application  of  arsenious  acid,  -^^  of  a  gi'ain,  may  be  used  to 
hasten  the  destruction  of  the  diseased  pulp,  or  the  constant  and  renewed 
applications  of  carbolic  acid  on  pellets  of  cotton-wool  may  attain  the  de- 
sired end.     The  tooth  may  then  be  afterward  filled. 

Cheonig  Inflammation  is  generally  the  sequel  of  acute  inflammation  of 
the  tooth-pulp,  and,  if  the  occuiTcnce  is  frequent,  the  tooth  had  better  be 
extracted.     The  pain  is  of  a  dull  and  gnawing  kind. 

Acute  Periodontitis  may  arise  from  a  blow,  or  be  the  sequel  of  acute 
inflammation  of  the  pulp,  or  may  arise  from  constitutional  causes,  such  as 
rheumatism  or  scrofula.  Pain  commences  with  a  feeling  of  uneasiness, 
which  increases  to  an  aching,  combined  with  great  tenderness  on  pressure. 
The  tooth  is  felt  long,  neighboring  teeth  become  involved,  and  the  inflam- 
mation spreads  to  the  palate  and  cheek,  which  is  swollen  and  oedematous. 
Suppuration  takes  place,  pus  is  formed,  and  an  abscess  may  burst  at  any 
point,  either  external  or  internal  to  the  dental  arch.  Treatment.  — If  the 
tooth  is  far  involved  in  caries,  extraction  of  the  offender  is  the  best  remedy. 
When  it  is  desirable  that  the  tooth  should  be  retained,  applications  of 

'  Contributed  by  Mr.  I.  Lyons,  Assistant  Dental  Surgeon  to  St.  Bartholomew's 
Hospital. 


TUBERCULOSIS.  291 

poultices  or  poppy  fomentations  are  of  great  benefit,  but  must  be  applied 
inside  the  mouth  only,  and  about  the  region  of  the  afifected  tooth  ;  or  local 
bleeding  by  leeches,  and  free  incisions,  and  the  prescribing  of  such  consti- 
tutional remedies  as  may  be  indicated. 

Chronic  Periosteal  Inflammation  is  generally  the  sequel  of  the  above 
disease.  The  character  of  pain  is  the  same  but  more  modified,  and  the 
treatment  is  nearly  always  extraction  of  the  tooth, 

Dental  Exostosis  is  an  outgrowth  of  osseous  tissue  from  the  surface  of 
the  cementum  of  the  fang.  The  usual  cause  of  it  is  chronic  periodontitis. 
The  pain  is  of  a  neuralgic  character.  Extraction  is  the  only  available 
remedy. 

Necrosis  arises  when  the  fang  of  a  tooth  becomes  denuded  of  its  perios- 
teum, and  its  most  frequent  cause  is  acute  periodontitis. 

Tuberculosis. — An  excellent  account,  by  Klein,  of  the  present  state 
of  knowledge  concerning  the  infectious  nature  of  tuberculosis  is  to  be 
found  in  the  Practitioner  for  August,  1881.  The  chief  practical  points 
are  that  (1)  the  possibility  of  infecting  cattle,  pigs,  and  sheep  by  feeding 
vnth  the  meat,  and  even  with  the  milk,  of  tuberculous  animals  has  been 
proved ;  that  (2)  the  materies  morbi  is  present  in  gray  or  caseous  tubercle, 
and  is  not  present  in  caseous  matter  which  has  not  been  derived  from  real 
tubercle  originally.  The  first  point  is  made  more  important  by  the  evi- 
dence offered  by  Creighton  of  the  transmissibility  of  bovine  tuberculosis 
to  man  by  means  of  milk.  All  this  lends  probability  to  statements  which 
have  over  and  over  again  been  made  of  the  infectiousness  of  phthisis. 
Klebs  and  Schiiller  have  observed  that  micrococci  are  constant  in  human 
tubercular  matter.  , 


NOTES   ON  OPHTHALMIC  SURGERY, 

BY  HENRY  JUICER,  F.E.C.S., 

BEKIOB    A83ISTA.IIT    SURGEON,    ROTAL  ITESTMINSTEB  OPHTHALMIC     HOSPITAL  ;   xtEHONSTRATOIt  OF  ANAT- 
OMT,  BT,  MART'S   HOSPITAL;    OLINIOAL   ABSISTAMT,   BOTAL   OPHTHAI.MIO   BOSFITAL,    MOOBriBLDB. 


Cataract — Central,  Cortical,  Lamellar,  Capsular,  Traumatic,  Secondary.  Opera- 
tions.    Spectacles. 

Choroid — Hyperemia,  Choroiditis,  Sclerotico-Choroiditis  Posterior,  Tubercle,  Tu- 
mors, Bone  Formation,  Coloboma,  Rupture. 

Ciliary  Region — Sympathetic  Irritation,  Sympathetic  Ophthalmitis. 

Conjunctiva — Ophthalmia,  Neonatorum,  Gonorrhaeal,  Mucopurulent,  Diphtheritic, 
Granular.     Xerophthalmia.     Pinguecala.     Pterygium. 

Cornea — Local  Keratitis,  Ulceration,  Hypopion,  Onyx,  Syphilitic  Keratitis,  Punctate 
Keratitis,  Arcus  Senilis,  Pannus,  Periotomy,  Conical  Cornea,  Wounds. 

Eyelids— Blepharitis,  Stye,  Tarsal  Tumor,  Warts,  Rodent  Ulcer,  Syphilitic  Ulcer, 
Lupus,  Naevus,  Ptosis,  Trichiasis,  Symblepharon,  Entropion,  Ectropion. 

Glaucoma — Acute,  Chronic,  Secondary. 

Iri8— Iritis,  Iridectomy,  Iridotomy,  Iridodesis,  Prolapse,  Coredialysis,  Congenital 
Irideremia,  Coloboma,  Mydriasis,  Myosis. 

Lachrymal  Apparatus — Mucocele,  Stricture  of  Nasal  Duct,  Fistula  of  Lachrymal 
Sac.    Lachrymal  Gland,  Diseases  of,  Excision  of. 

Optic  Nerve — Optic  Neuritis,  Atrophy. 

Retina — Retinitis,  Syphilitic.  Albuminuric,  Apoplectic,  Pigmented.  Detachment. 
Glioma. 

Refraction — Emmetropia,  Ametropia,  Presbyopia,  Myopia,  Hypermetropia,  Astig- 
matism. 

Strabismus — Internal,  External,  Operation, 


Cataract  is  an  opacity  of  tbe  crystalline  lens.  Various  classifications 
are  used.  The  following  is  perhaps  the  best :  (1)  Central ;  (2)  Cortical  ; 
(3)  Lamellar ;  (4)  Capsular  ;  (5)  Traumatic ;  (6)  Secondary. 

1.  Central  OR  Nuclear. —Opacity  begins  at  the  centre  and  shades  oflf 
toward  circumference.  It  mostly  occurs  in  old  people,  when  it  is  hard  at 
the  centre  and  of  amber  color.  When  occurring  before  the  age  of  thirty- 
five  it  is  softer  and  whiter. 

2.  Cortical  or  Raduting.— Opacity  begins  at  the  surface  of  lens  as 
triangular  or  pyramidal  streaks  pointing  toward  centre.  When  advanced 
they  involve  whole  structure  of  lens. 


CATARACT.  293 

3.  Lamellae  or  Zonular. — Opacity  consists  of  a  shell-like  layer  depos- 
ited within  the  substance  of  the  lens  at  a  variable  distance  from  its  sur- 
face. It  occurs  in  very  young  subjects  (1  to  3  months),  and  is  sometimes 
congenital ;  the  subjects  of  it  frequently  suffer  from  infantile  convulsions. 

4.  Capsular. — (a)  Pyramidal ;  (6)  Posterior  Polar,  (a)  Pyramidal. — 
Occurs  as  a  very  white  well-defined  opacity  on  front  part  of  lens  just 
beneath  the  capsule.  It  is.  generally  caused  by  ulcer  of  cornea  follow- 
ing purulent  ophthalmia,  and,  consequently,  is  generally  associated  with 
opacity  of  cornea.  (6)  Posterior  Polar. — Begins  at  posterior  part  of  chief 
axis  of  lens  and  radiates  ;  generally  associated  with  disease  of  choroid  and 
vitreous. 

5.  Traumatic. — Follows  wound  of  the  lens  capsule  by  which  the  aque- 
ous humor  is  admitted  to  the  lens  substance,  causing  sweUing,  opacity,  and 
final  absorption  of  this,  and  leaving  only  a  chalk-like  deposit  upon  the  re- 
maining capsule. 

6.  Secondary  Cataract  is  so  called  when  it  is  the  result  of  some  other 
local  disease,  as  glaucoma,  irido-cyclitis,  etc.,  or  of  some  general  disease, 
as  diabetes  mellitus. 

Any  combination  of  the  above  forms  would  be  called  a  mixed  cataract. 
The  degree  of  hardness  of  a  cataract  depends  chiefly  upon  the  age  of  the 
patient,  all  cataracts  occurring  before  the  age  of  thirty-five  being  "  soft." 

Diagnosis. — Gradual  failure  of  sight  without  local  inflammatory  symp- 
toms is  a  subjective  indication  of  cataract.  A  grayish  appearance  of  the 
pupil  is  often  observed  in  old  people,  which  is  not  due  to  cataract,  the  lens 
being  transparent.  When  the  presence  of  cataract  is  suspected  the  pu- 
pil should  be  dilated  by  atropine  and  examined.  (1)  By  daylight,  dif- 
fused rays  condensed  upon  the  pupil  with  a  convex  lens.  (2)  By  gaslight 
in  a  similar  way.  These  will  give  a  white,  amber-like,  or  brownish  ap- 
pearance of  lens.  (3)  By  the  ophthalmoscope,  when  the  opacity  of  lens 
will  appear  as  dark  patches,  streaks,  or  a  central  nucleus  ;  the  red  cho- 
roidal reflex  will  only  be  observed  inversely  as  the  amoimt  of  opacity.  In 
lamellar  cataract,  a  well-defined  shell  of  opacity  appears,  surrounded  by  a 
clear  (cortical)  layer  of  lens  substance,  through  which  the  bright  red  cho- 
roidal reflex  is  observed.  When  any  portion  of  the  lens  substance  remains 
clear,  note  should  be  made  as  to  the  state  of  the  vitreous,  optic  disc,  ret- 
ina, and  choroid,  with  a  view  to  probable  fitness  for  future  operation. 
Opacities  of  cornea  will  also  appear  as  dark  patches  with  ophthalmoscope, 
and  may  be  seen  by  superficial  examination.  Opacities  of  vitreous  appear 
as  moving  bodies,  and  are  distinguished  by  their  continuing  to  move  after 
the  patient's  eye  has  suddenly  come  to  rest. 

Treatment. — In  early  stages  of  nuclear  cataract  the  sight  may  often  be 
improved  by  moderate  dilatation  of  the  pupil  by  atropine.  Use  atropine 
drops,  gr.  iv.  ad  3  j.,  once  or  twice  a  week.  Dai-k  spectacles  may  be  worn 
to  favor  dilatation  of  the  pupil.     In  lamellar  cataract  patient  can  often 


294  CATARACT. 

see  fairly  well.  When  vision  is  seriously  impaired  and  the  margin  of 
translucency  is  wide,  make  an  artificial  pupil  by  iridectomy ;  when  the 
margin  is  narrow,  perform  the  operation  of  solution,  or  of  extraction.  In 
forms  other  than  lamellar,  sight  can  be  restored  only  by  one  of  the  follow- 
ing methods  of  operating  on  the  lens  :  (1)  Extraction  ;  (2)  Needle  opera- 
tion ;  (3)  Suction.  (1)  Extraction. — Various  methods  are  in  use  at  the  pres- 
ent time,  but  all  have  the  following  common  points :  (1)  An  incision  in 
the  cornea  or  at  the  junction  of  the  cornea  and  sclerotic,  or  in  the  sclerotic 
just  beyond  the  cornea,  sufficiently  large  to  allow  exit  of  lens.  The  inci- 
sion is  usually  made  with  Von  Graefe's  straight  knife.  (2)  Iridectomy  is 
very  freqiiently  performed,  either  as  a  second  stage  of  the  operation  or 
two  or  three  weeks  previously.  This  is  done  to  lessen  the  danger  of  iri- 
tis, which  more  frequently  follows  the  older  operation  in  which  iridectomy 
was  not  performed.  (3)  The  capsule  is  freely  ruptured  by  a  sharp-pointed 
instrument  introduced  through  the  corneal  wound.  (4)  The  lens  is  re- 
moved through  the  torn  capsule,  either  by  pressure  and  manipulation  out- 
side the  eye  or  by  means  of  a  scoop  passed  behind  the  lens.  The  chief 
types  of  operation  for  extraction  are :  (1)  Graefe's  Modified  Linear  or  Periph- 
eral Linear. — Here  the  incision  is  made  with  a  long,  narrow  knife,  slightly 
beyond  the  sclero-comeal  junction,  involving  conjunctiva  and  forming  a 
small  arc  of  a  circle  larger  than  the  cornea,  the  plane  of  incision  forms  a 
large  angle  with  that  of  the  iris.  Iridectomy  follows  the  incision.  (2) 
The  incision  has  nearly  the  same  cui-ve  as  the  above,  but  is  not  carried 
so  far  toward  sclerotic,  being  mostly  in  the  cornea.  Iridectomy  is  not 
usually  performed  here.  (3)  Flap  Operation  (old). — Incision  just  within 
margin  of  cornea,  and  concentric  with  it,  equal  to  half  its  circumference, 
and  parallel  to  plane  of  iris.  Beer's  triangular  knife.  No  iridectomy. 
Disadvantages  of  modified  linear  operation  :  Frequent  hemorrhage  into 
anterior  chamber.  Greater  risk  of  loss  of  vitreous.  Risk  of  irritability 
from  prolapse  of  iris  into  corners  of  wound,  and  of  sympathetic  ophthal- 
mitis in  the  other  eye.  Disadvantages  of  the  old  flap  operation  :  The 
large  flap  is  hable  to  gape  or  fall  forward,  causing  sloughing.  Frequent 
prolapse  of  iris.  Frequent  severe  iritis.  After-treatment  for  either  of 
these  methods. — Keep  the  patient  in  bed  for  a  week.  Apply  a  piece  of 
soft  linen  to  the  closed  eyehds,  and  a  pad  of  cotton  wool  over  this  to  both 
eyes,  and  secure  by  a  four-tailed  bandage.  Keep  the  room  nearly  dark. 
Remove  dressing,  and  gently  cleanse  the  lids  with  warm  water  twice  daily, 
just  separating  their  edges  to  allow  escape  of  tears  that  may  be  retained. 
Use  one  drop  of  atropine  solution  daily  after  the  third  day  to  prevent  iritic 
adhesion.  Diu-ing  the  first  few  hours  there  will  be  some  soreness,  and  the 
fiirst  dressing  a  little  blood-stained  ;  after  this  there  should  be  no  pain,  and 
only  a  little  mucous  discharge.  If  doing  well  there  will  be  slight  conges- 
tion, but  no  chemosis,  edges  of  wound  united,  and  pupil  black.  Discon- 
tinue bandage  after  eight  or  ten  days,  and  order  a  large  shade. 


CATARACT.  295 

2.  Needle  Operation  foe  Solution.  — (1)  Dilate  pupil  by  atropine.  (2) 
Give  anaesthetic  unless  the  patient  is  old  enough  to  control  himself  well. 
(3)  Hold  lids  open  by  stop-speculum,  and  use  fixation  forceps  to  steady 
globe.  (4)  Direct  a  fine  cataract  needle  to  a  point  just  within  the  margin 
of  the  cornea,  plunge  freely  and  obliquely  through  into  anterior  chamber, 
and  carry  point  to  centre  of  pupil.  (5)  Dip  point  of  needle  back  thi-ough 
the  capsule  into  superficial  layers  of  lens  at  centre,  make  a  few  gentle  to 
and  fro  movements,  so  as  to  break  up  its  substance,  then  steadily  withdraw 
the  needle.     After-treatment. — Dilate  the  pupil  with  atropine  (gr.  iv.  ad 

I  j.)  three  times  daily.  Bandage  the  eye  lightly,  and  employ  dark  room 
for  several  days.  In  case  of  iritis  apply  leeches  to  region  of  eye,  and  ice 
or  evaporating  lotions  to  lids.  The  result  varies  with  the  amount  of  the 
opacity  of  the  lens.  In  cases  of  complete  cataract  no  marked  change  will 
be  observed  for  some  weeks  after  operation.  In  partial  cataract  the  rup- 
tured portion  of  the  lens  will  become  opaque  and  swollen  in  a  few  days, 
and  in  seven  weeks  the  lens  will  be  smaller.  After  six  to  eight  weeks,  if 
the  eye  be  perfectly  quiescent,  and  not  otherwise,  the  operation  may  be 
repeated,  and  the  needle  used  more  freely.  A  third  or  fourth  operation 
may  be  required. 

3.  Suction  Operation. — Only  applicable  to  soft  cataract,  and  requires 
great  skill  in  its  performance,  to  avoid  danger  of  iritis,  or  cyclitis.  (1) 
Dilate  pupil  with  atropine.  (2)  Make  oblique  opening  in  cornea  with  a 
broad-cutting  needle  between  its  centre  and  its  margin,  and  lacerate  cap- 
sule freely.  (3)  Withdraw  needle  and  pass  nozzle  of  syringe  through 
wound,  and  dip  into  lacerated  lens-substance.  In  lamellar  cataract,  and 
some  other  cases,  it  is  necessary  to  allow  an  interval  of  three  days  between 
the  needle  operation  and  the  suction,  in  order  that  the  lens  may  be  soft- 
ened by  the  admission  of  the  aqueous.  (4)  Use  very  gentle  suction,  and 
repaove  if  possible  the  whole  of  lens-substance  at  one  sitting.  After-treat- 
ment is  the  same  as  for  needle  operation  (but  in  the  case  of  waiting,  careful 
watch  must  be  made,  and  suction  performed  at  once  if  inflammation  be  set 
up  by  the  rapid  swelling  of  the  lens). 

When  to  Perform.  Extraction. — The  more  complete  the  opacity  of  the 
lens,  the  more  easily  is  it  shelled  out  of  its  capsule,  whilst  in  immature 
cataract  some  of  the  transparent  lens-substance  is  apt  to  remain  ;  this 
will  become  opaque  and  may  interfere  with  result  of  operation.  The 
signs  of  this  "  ripe  "  condition  are  :  (1)  No  shadow  of  iris  thrown  upon 
lens  within  the  pupillary  area  ;  (2)  no  choroidal  reflex  wdth  ophthalmo- 
scope ;  (3)  patient  is  able  to  distinguish  light  from  darkness,  but  is,  un- 
able to  coimt  fingers  when  held  up  before  the  eyes.  When  one  eye  only 
is  affected,  or  when  one  is  less  affected  than  the  other,  extraction  should 
be  deferred  until  the  better  eye  is  no  longer  useful,  unless  for  special 
reasons.  When  both  cataracts  are  mature,  only  one  should  be  operated  07i 
at  a  time,  with  an  interval  of  a  few  months.     When  there  is  no  percep- 


296  CHOROID. 

tion  of  ligiit  do  not  operate,  as  cataract  alone  is  not  sufficient  to  prevent 
this. 

Occasional  Results  of  Extraction. — 1.  Sloughing  of  cornea,  very  rare 
since  flap  operation  was  abandoned.  2.  Suppurative  inflammation  extend- 
ing from  wovind  to  the  whole  cornea,  iris,  and  vitreous,  variable  in  degree, 
but,  when  established,  generally  going  on  to  suppurative  panophthalmitis, 
or  to  severe  plastic  irido-cyclitis  with  corneal  opacity  and  contraction  of 
eyeball.  3.  Iritis  of  a  plastic  nature  which  deposits  a  membrane  in  pupil- 
lary area.  4.  Prolapse  of  iris  into  the  wound,  either  at  the  time  of  opera- 
tion or  afterward. 

Conditions  of  Sight  after  Operation. — Kesults  are  good  when,  with  the 
aid  of  proper  spectacles,  patient  can  read  any  of  Snellen's  test  tj-pes  from 
No.  1  to  No.  14  at  22  centimetres  (8  inches),  and  from  No.  6  to  No.  24  at 
6  metres  (20  feet).  The  operation  renders  the  eye  very  hypermetropic  for 
want  of  the  lens.  Very  strong  convex  glasses  are  required  to  compensate 
for  its  absence.  Glasses  should  not  be  worn  for  three  months  after  opera- 
tion, and  then  not  continuously  at  first.  Two  pairs  of  spectacles  are  needed, 
one  pair  making  the  eye  emmetropic  and  giving  clear  vision  for  distant 
objects  (about  -f  12  dioptres),  the  other  pair  stronger,  to  render  the  eye 
myopic,  so  that  the  patient  is  able  to  read,  etc.,  at  about  8  or  10  inches 
(about  +  16  dioptres). 

Choroid.  —  Diseases.  —  1,  Hypercemia  ;  2,  Choroiditis ;  3,  Sclerotico- 
choroiditis  Posterior  ;  4,  Tubercle  ;  5,  Tumors ;  6,  Bone  Formation  ;  7,  Colo- 
bonia  ;  8,  Rupture. 

Choroiditis  may  be  (1)  Syphilitic,  (2)  Simple,  (3)  Suppurative. 

Syphilitic  Choroiditis  is  the  most  common.  It  is  characterized  by  the 
presence  of  numerous  distinct  patches  scattered  about  fundus,  but  most 
abundant  toward  periphery ;  they  are  at  first  of  a  yellowish  red  appear- 
ance, which  soon  changes  to  yellowish  white  or  glistening  white,  accord- 
ing to  the  extent  of  choroidal  atrophy.  The  patches  are  more  or  less  pig- 
mented. Vision  is  affected  in  proportion  to  the  extent  of  the  disease. 
Usually  no  pain.  Generally  a  history  of  acquired  or  inherited  syphilis. 
Treatment. — Mercury  combined  with  iodide  of  potassium.  Eest  of  eyes 
by  means  of  dark  room.  Artificial  leech  or  dry  cupping  to  temples.  In 
the  early  stage  mercury  does  great  good,  and  in  old  cases  where  failure  of 
sight  is  increasing  it  should  be  given.     Prognosis,  guarded. 

Simple  Choroiditis. — In  this  form  the  jjatches  of  atrophy  are  similarly 
distributed  but  are  confluent  (compare  with  syphilitic  form).  Or,  large 
areas  of  incomplete  atrophy  are  interspersed  with  separate  patches,  or 
there  may  be  a  widespread  superficial  atrophy  with  pigmentation.  The 
field  of  vision  is  here  also  affected  in  proportion  to  bhe  change. 

Suppurative  Choroiditis  is  acute,  and  occurs  in  conjunction  with  similar 
inflammation  of  neighboring  parts  (panophthalmitis). 

Sclerotico-choroiditis  Posterior  is  limited  to  the  regions  of  the  optic 


CILIAEY   REGION.  297 

disc  and  yellow  spot,  which  present  many  varieties  df  localized  change.  It 
is  common  in  myopic  eyes,  and  the  appearances  thus  pro(Juced  are  known 
as  "posterior  staphyloma,"  "myopic  crescent,"  etc. 

Tubercle  of  Choeoid  appears  in  the  form  of  small  circular,  circum- 
scribed spots  (0.3  to  2.5  mm.),  situated  chiefly  in  the  region  of  optic  disc. 

TuMOES. — 1,  Sarcoma  ;  2,  Carcinoma. 

Bone  Formation  sometimes  occiufs  on  the  inner  surface  of  choroid  of 
eyes  which  have  been  long  destroyed  ;  it  varies  in  thickness  from  a  mere 
film  to  a  dense  osseous  cup. 

RuPTDEE  OF  Choroid  may  occur  from  a  blow  on  the  globe  and  may 
exist  with  or  without  rupture  of  other  coats.  Hemorrhage  at  once  occurs, 
and  blood  may  be  effused  (1)  between  choroid  and  retina  ;  (2)  between 
choroid  and  sclerotic  ;  (3)  into  vitreous. 

Ciliary  Region. — Sympathetic  Irritation  and  Sympathetic  Ophthalmi- 
tis.— In  sympathetic  irritation  the  changes  in  the  sympathizing  eye  are 
chiefly  functional.  In  sympathetic  ophthalmitis  they  are  of  a  destructive 
inflammatory  kind. 

Pathology. — The  exact  mode  of  transmission  from  the  exciting  to  the 
sympathizing  eye  is  not  well  known.     Very  interesting  facts  are  known. 

1.  The  change  commences  in  the  region  of  the  ciliary  body  and  iris  of 
the  exciting  eye,  and  its  effects  are  mostly  seen  in  the  corresponding  pai't 
of  the  sympathizing  eye.  This  region  is  richly  supplied  by  branches  of 
ciliary  nerves  (fifth,  sympathetic,  and  third). 

2.  In  exciting  eye  inflammatory  changes  are  always  found,  and  in  some 
cases  have  been  found  to  extend  to  the  ciliary  nerves.  It  is  considered 
probable  that  the  disease  passes  along  the  ciliary  nerves,  probably  as  neu- 
ritis, to  some  nerve-centre,  and  thence  to  the  other  eye. 

3.  The  optic  nerve  is  considered  to  have  no  part  in  the  transmission  of 
the  inflammation  ;  but  the  space  between  the  dural  and  pial  sheaths  of  the 
optic  nerve  is  a  probable  channel  of  communication. 

Symptoms  in  Sympathizing  Eye. — 1.  Irritation. — Eye  extremely  weak 
and  irritable  ;  patient  may  be  able  to  read  No.  1  of  Snellen's  type,  but  soon 
becomes  tired,  because  the  power  of  prolonged  accommodation  fails.  Eye 
sometimes  reddened,  may  be  watery  ;  neuralgic  pains  common.  Iris  not 
affected.  No  plastic  exudation  nor  disorganizing  changes  take  place.  Liable 
to  recur.     Excision  of  exciting  eye  at  once  cures  the  disease. 

2.  Ophthalmitis. — Begins  from  one  to  three  months,  or  more,  after 
affection  of  exciting  eye.  May  be  ushered  in  by  irritation.  May  be  well 
marked  from  the  first,  or  may  commence  in  a  manner  so  insidious  as  to 
escape  notice.  It  consists  chiefly  of  irido-cyclitis  or  irido-choroiditis,  the 
iritis  evincing  a  tendency  to  the  formation  of  tough  and  extensive  syne- 
chiae.  There  is  a  zone  of  ciliary  congestion.  Thickening  and  muddy  ap- 
pearance of  iris.  Tendency  to  formation  of  dots  of  opacity  (keratitis 
punctata)  on  the"  posterior  layer  of  the  cornea.     The  vitreous,  when  the 


298  CONJUNCTIVA. 

condition  of  the  pupil  allows  it  to  be  seen,  presents  floating  opacities. 
There  may  be  ncuro-retinitis.  Tension  of  globe  often  increased.  In  the 
mildest  forms  of  the  disease  there  may  be  only  slight  serous  iritis.  In  se- 
vere cases  the  eye  either  shiinks  or  may  become  glaucomatous  with  bulging 
of  the  sclerotic,  total  posterior  synechia,  secondary  cataract. 

Treatment. — 1.  When  there  is,  as  yet,  neither  sympathetic  irritation  nor 
sympathetic  ophthalmitis,  the  injured  eye  must  be  watched  as  to  the  seat 
of  its  inflammation,  and,  if  this  is  found  to  threaten  the  iris  and  ciHary  re- 
gion, precaution  must  be  taken  to  do  all  that  is  possible  to  subdue  it. 
Atropine  should  be  applied.  Patient  kept  in  dark  room  for  long  period  ; 
eye  bandaged.     Mild  mercurials  and  iodide  of  potassium  internally. 

2,  If  irritation  is  set  up,  the  foregoing  remedies  to  be  appUed  to  both 
eyes,  and  if  the  exciting  eye  is  past  hope  of  recovery  it  should  be  excised  at 
once. 

3.  If  ophthalmitis  is  established  and  exciting  eye  quite  blind  it  should 
be  excised  at  once  ;  but  if  any  useful  sight  remains  it  should  be  saved,  aa 
it  may  prove  the  better  eye  in  the  end. 

In  the  latter  case  do  all  you  can  to  save  both  the  exciting  and  the  sym- 
pathizing eye.  (1)  Use  atropine  drops  every  few  hours  ;  (2)  rest  the  eyes 
by  exclusion  of  light ;  (3)  apply  leeches,  bHsters,  warm  fomentations,  etc. ; 
(4)  give  mercurials. 

Do  not  perform  any  operation  on  the  eye  imtil  inflammation  has  sub- 
sided, 

Coryunctiva. — Ophthalmia. — This  term  is  applied  to  all  forms  of  con- 
junctivitis. Chief  forms  are — 1,  Purulent ;  2,  Muco-purulent ;  3,  Membra- 
nous;  4,  Granular. 

PuBULENT  OpHTHALisnA  is  generally  due  to  contact  with  pus  from  the 
urethra  or  vagina,  which  may  be  gonorrhoeal  or  otherwise.  The  quality  of 
the  infecting  discharge  greatly  influences  the  nature  of  the  ophthalmia. 
When  caused  by  gonorrhoea  the  coTirse  is  very  violent.  When  occurring  in 
newly  born  children  it  is  called  O.  neonatorum. 

Symptoms. — In  from  twelve  to  forty-eight  hours  after  infection  there 
are  itching  and  slight  injection  of  the  conjunctiva,  these  soon  become  in- 
tense ;  then  chemosis,  tense  swelling  of  the  Uds,  great  pain  and  discharge, 
at  first  serous,  then  turbid,  then  uniformly  purulent.  If  untreated  the 
discharge  ceases  in  about  six  weeks,  leaving  the  palpebral  conjunctiva 
thickened,  relaxed,  and  more  or  less  granular.  Cicatricial  changes  follow. 
The  cornea  is  in  danger  from  two  chief  causes,  viz.:  (1)  strangulation  of 
the  vessels  from  pressure,  and  (2)  the  influence  of  the  discharge.  If  with- 
in the  first  few  days  the  cornea  be  hazy  and  dull,  it  may  partly  or  entirely 
slough.  In  milder  cases  transparent  ulcers  may  appear  and  sometimes 
cause  perforation.     In  many  cases  no  corneal  opacity  occurs. 

Treatment. — When  one  eye  only  is  affected,  carefully  protect  the  other 
by  a  watch-glass   strapped  on.      Frequently  and  thoroughly  remove  the 


CONJUNCTIVA.  299 

discharge  by  free  douching  with  water.  Use  astringent  or  caustic  lotions 
or  drops  every  hour  in  severe  cases,  e.g.,  lotio  aluminis,  gr.  x.  ad  ^  j.;  lo- 
tio  zinci,  gr.  x.  ad  3  j.;  lotio  hydrarg.  perchlor.,  gr.  ^  ad  3  j.;  lotio  argent, 
nit.,  gr.  ij.  ad  3  j.  Apply  simple  ointment  to  the  eyelids  to  prevent  adhesion. 
Evert  the  lids  and  brush  a  strong  solution  of  nitrate  of  silver  (gr.  x.  or  xx. 
ad  3  j.)  freely  over  the  conjunctiva  once  daily,  and  well  wash  off  immedi- 
ately afterward  either  with  water  or  with  solution  of  common  salt.  Repeat 
less  frequently  as  the  discharge  diminishes.  In  cases  where  the  lids  are 
so  swollen  that  nothing  can  be  appHed  to  their  conjunctival  surfaces,  the 
outer  canthus  can  be  divided,  or  Mr.  Critchett's  method  of  dividing  the 
upper  lid  by  a  vertical  iacision  can  be  adopted. 

Treatment  should  be  continued  as  long  as  any  discharge  or  granula- 
tions remain  on  the  lids,  for  fear  of  a  relapse  which  is  apt  to  occvu\ 

Muco-PUEULENT  OPHTHALMIA  (Catarrhal  Ophthalmia). —  Very  common, 
very  contagious,  mostly  attacks  both  eyes,  differs  in  severity  in  members  of 
the  same  household,  who  are  generally  attacked  at  the  same  time.  Symp- 
toms.— Congestion  of  conjunctiva,  with  patches  of  ecchymosis.  Gritty 
pain,  sometimes  severe.  Spasm  of  Hds.  Free  muco-puinilent  discharge. 
Lids  somewhat  swollen  and  red,  never  tense.  The  cornea  seldom  suffers. 
Spontaneous  recovery  takes  place  in  about  two  weeks.  Treatment. — Any 
mild  astringent  lotion  or  drops  will  cut  the  malady  short.  An  outbreak 
of  this  malady  in  a  crowded  community  is  serious.  Very  common  in  pau- 
per schools. 

Membranous  Ophthalmia  (Diphtheritic  Ophthalmia). — Very  rare  in  this 
country,  and  must  not  be  confused  with  muco  purulent  or  purulent  oph- 
thalmia, in  which  there  is  often  a  distinct  layer  of  inspissated  pus  beneath 
the  Hds.  In  membranous  ophthalmia  the  whole  thickness  of  the  conjunc- 
tiva is  occupied  by  a  solid  exudation,  which  is  called  "  diphtheritic "  by 
some  surgeons.  It  may  appear  in  patches,  or  may  cover  all  the  whole  ia- 
side  of  the  lids. 

Granular  Ophthalmia. — Very  common.  Symptoms. — Firstly,  appear- 
ance as  of  small  granules  like  sago-grains  on  the  inner  surface  of  the  lower 
lid,  due  to  inflamed  lymphatic  folhcles.  These  extend  to  upper  Hd  ;  then 
progressive  changes  in  the  palpebral  conjunctiva  in  which  it  becomes  thick- 
ened, vascular,  and  roughened  by  granular  elevations.  New  tissue  is 
formed  in  the  deep  parts  of  the  conjunctiva,  which  afterward  is  partly  ab- 
sorbed, and  partly  undergoes  cicatricial  contraction.  Causes. — Feeble 
health.  Prolonged  residence  in  badly-ventilated  dwellings.  Treatment. 
—  Generally  tedious.  Evert  the  eyelids  and  ai3ply  a  solution  of  nitrate  of 
silver  (gr.  xx.  ad  3  j.)  with  camel's-hair  brush,  once,  twice,  or  thrice  a  week; 
or  apply  the  mitigated  nitrate  of  silver  stick  ;  in  each  case  wash  the  lids 
with  water  before  inverting  them.  Solid  sulphate  of  copper  may  be  used 
instead  of  these.  Glycerine  of  tannin  applied  daily  is  beneficial.  Results. — 
(1)  Haziness  of  cornea  ;  (2)  Pannus  (see  cornea)  ;  (3)  Entropion,  Trichiasis 


300  CORNEA. 

Xerophthalmia  (Xerosis,  Cuticlar  Conjunctiva)  is  a  condition  of  exces- 
sive dryness  of  the  ocular  and  palpebral  conjunctivae. 

Pterygium  is  a  triangular  patch  of  thickened  conjunctiva,  generally 
placed  opposite  the  palpebral  fissure,  its  apex  pointing  to  or  encroaching 
upon  the  cornea.  Kare  in  this  country.  Treatment. — Dissect  up  from 
apex  and  transplant  it  into  a  cleft  below  the  cornea.  This  is  said  to  be 
more  effectual  than  excision  or  ligature. 

Pinguecula,  a  harmless  patch  of  yellowish  white  thickened  conjunctiva 
situated  near  margin  of  cornea. 

Lupus  may  occur  on  conjunctiva. 

Warts  are  sometimes  seen  on  the  ocular  and  palpebral  conjunctivae ; 
they  are  cauliflower  excrescerices.     To  be  snipped  off  with  scissors. 

Epithelioma  and  Sarcoma  may  occur  on  the  Conjvmctiva. 

Cornea. — Inflammation  of  the  cornea  may  be  circumscribed  or  diffused, 
may  involve  its  proper  layers,  or  may  be  confined  to  its  anterior  or  poste- 
rior epitheUal  layer.  It  may  be  local,  leading  generally  to  suppuration  or 
ulceration,  or  it  may  arise  from  constitutional  disease,  as  inherited  syphilis. 
It  may  exist  with  other  inflammations,  as  in  kerato-iritis,  cyclo-iritis. 

Local  Keratitis  (Comeitis). — Symptoms. — Commences  with  a  more  or 
less  perfect  zone  of  pinkish-red  vessels  around  the  margin  of  the  cornea. 
Photophobia  more  or  less  severe.  Cornea  becomes  hazy,  and  has  a  steamy 
or  ground-glass  appearance.  Generally  there  is  lachrymation,  and  fre- 
quently pain  in  and  around  the  eye.  Pathology.— The  intercellular  sub- 
stance becomes  opaque  from  infiltration  with  leucocytes,  which  are  sup- 
posed to  have  emigrated  from  the  surrounding  vessels.  The  cells  of  the 
corneal  tissue  proper  also  undergo  proliferation  into  small  corpuscles, 
greatly  resembUng  leucocytes.  The  disease  often  has  a  tendency  toward 
recovery,  but  more  frequently  leads  to  suppuration  and  ulceration. 

Ulceration  of  Cornea  is  preceded  by  inflammatory  infiltration,  and  the 
inflamed  part  breaks  down  at  the  centre,  forming  an  ulcer  with  more 
or  less  infiltrated  base  and  edges.  S'j/m^toms.— Photophobia,  congestion 
more  or  less,  consisting  of  a  circular  zone  of  vessels  beneath  the  conjunc- 
tiva at  periphery  of  cornea,  and  sometimes  also  of  conjunctival  vessels. 
Pain  sometimes  acute, 

Ulcers  may  be  (1)  small  and  central,  uxith  infiltration  of  base  and  edges. 
These  generally  heal  quickly,  but  leave  a  hazy  (nebula)  or  an  opaque  spot 
(leucoma). 

2.  Small  and  central,  imthout  much  infiltration.  These  heal  slowly  and 
with  loss  of  tissue,  perhaps  without  opacity,  but  give  a.  facetted  appearance 
to  the  cornea. 

3.  Phlyctenular  ulcers  (Herpes  comeae). 

4.  Serpiginous  ulcers. 

5.  Acute  suppurating  ulcer  following  abscess  or  otherwise.  Treatm,ent. 
— ^First  secure  rest,  either  by  bandaging  the  affected  eye,  and  so  reducing 


CORNEA.  301 

friction  against  eyelids,  or  by  shading  both  eyes.  Soothe  local  pain  by 
atropine  drops.  In  suppurating  cases  apply  hot  fomentations  to  lids  ;  if 
abscess  is  defined,  open  by  valvular  incision.  When  indolent,  stimulate 
ulcer  by  astringent  drops,  ointment  of  yeUow  oxide  of  mercury,  calomel 
powder,  eserine  drops  (gr.  iij.  ad.  f  j.),  etc. 

Counter-irritants  to  temple,  as  seton  or  blister.  Constitutional  treat- 
ment. 

Hypopion  signifies  a  collection  of  pus  or  purolymph  in  the  lowest  part 
of  the  anterior  chamber.  The  pus  is  derived  (1)  from  the  rupture  of  an 
abscess  through  the  posterior  layer  of  the  cornea ;  (2)  from  suppuration  of 
the  epitheloid  layer  covering  Descemets' membrane  ;  (3)  from  surface  of  iris. 

Onyx  is  a  term  applied  to  that  condition  in  which  pus  is  observed  be- 
tween the  layers  of  the  cornea  at  its  lower  part. 

SYPHTLnic  EJERATiTis  (Interstitial  K.  Parenchymatous  K.). — Symptoms. 
— The  visible  changes  of  the  cornea  are  usually  preceded  for  a  few  days  by 
some  ciliary  congestion  and  lachrymation  ;  then  there  is  cloudiness  in  one 
or  more  patches,  and  after  a  few  weeks  a  ground-glass  appearance.  Fre- 
quently accompanied  by  iritis  and  posterior  synechise.  Blood-vessels  often 
appear  in  the  layers  of  the  cornea,  extending  from  the  ciHary  vessels  ;  they 
are  thickly  set  in  patches  (salmon  patches)  of  a  reddish  pink  color,  and  of 
various  shapes ;  they  may  extend  all  over  the  cornea,  except,  perhaps,  to 
the  immediate  centre.  The  disease  is  always  symmetrical  (contrast  with 
local  keratitis),  but  second  eye  is  usually  attacked  a  few  weeks  after  the 
first.  Age  generally  between  six  and  fifteen.  Often  accompanied  by  in- 
flammation of  the  ciliary  region  and  iris,  which  may  give  rise  to  secondary 
glaucoma,  to  stretching  and  elongation  of  the  globe  in  the  ciliaiy  zone,  or 
to  softening  of  the  eyeball ;  but,  as  a  rule,  the  comea  throughout  its  whole 
structure  undergoes  a  chronic  inflammation,  showing  no  tendency  either 
to  suppuration  or  ulceration,  the  inflammatory  products  being  partially  or 
entirely  absorbed  after  several  months.  Cause. — Inherited  syphilis.  Other 
signs  of  inherited  syphilis  are  usually  present.    [See  Congenital  Syphhjs.) 

If  no  other  signs  are  shown  in  the  patient,  a  history  of  infantile  syphilis 
can  generally  be  ascertained,  either  in  the  patient  or  his  brothers  and 
sisters  ;  or  a  history  of  acquired  syphilis  in  the  parents  may  be  traced.  A 
few  cases  have  been  seen  in  which  this  disease  has  occurred  as  the  result  of 
acquired  syphUis. 

Treatment. — A  long  but  mild  course  of  mercury.  Mercmial  inunction, 
gray  powder,  blue  pill,  etc.  Iodide  of  potassium  may  be  combined  with 
these.  Keep  a  strict  watch  against  salivation.  If  the  patient  be  anfemic 
or  strumous,  give  iodide  of  iron,  bark,  quinine,  etc.  Keep  the  eyes  shaded. 
Use  atropine  drops  daUy,  as  iritis  may  occur  without  being  detected 
through  the  opaque  cornea.  When  inflammation  has  subsided,  apply 
calomel  powder  or  ointment  of  yellow  oxide  of  mercury  to  the  cornea 
daily,  in  order  to  promote  the  absorption  of  the  opacity. 


302  EYELIDS. 

KERATirrs  Punctata  is  characterized  by  the  presence  of  small  dots  of 
opacity  on  the  posterior  elastic  lamina  of  the  cornea.  They  are  generally 
arranged  in  the  form  of  a  triangle,  having  its  apex  at  the  centre,  and  its 
base  toward  the  lower  margin  of  the  cornea.  This  condition  is  generally 
secondary  to  some  form  of  inflammation  of  iris.  It  is  frequently  seen  in 
sympathetic  ophthalmitis. 

Arcus  senilis  is  caused  by  fatty  degeneration  of  the  corneal  tissue  just 
within  its  margin. 

Pannus  is  the  result  of  friction  from  a  granular  condition  of  the  upper 
lid,  trichiasis,  etc.  It  is  characterized  by  haziness  of  the  cornea,  with 
vascularity,  the  vessels  being  continuous  with  those  of  the  conjunctiva,  and 
the  anterior  layers  of  the  cornea  more  or  less  infiltrated  with  plastic  mat- 
ter. Treatment. — 1.  Try  to  cure  the  granular  lids.  2.  The  operation  of 
syndectomy  or  peritoniy — that  is,  the  removal  of  a  zone  of  conjunctival  and 
sub-conjunctival  tissue  from  around  the  cornea — is  strongly  recommended 
by  Mr.  Critchett  in  old  intractable  cases  of  pannus.  3.  Very  severe  and 
universal  pannus  is  best  treated  by  inoculation  with  pus  from  purulent 
ophthalmia,  or  even  from  gonorrhoeal  discharge.  It  is  a  severe  remedy, 
and  may  be  followed  by  sloughing  of  cornea.  It  should  never  be  resorted 
to  if  there  is  any  portion  of  the  cornea  transparent. 

Conical  Cornea  is  caused  by  a  bulging  forward  of  the  central  part  of 
the  cornea  forming  a  blunt  conical  curve,  which  gives  rise  to  irregular 
astigmatism  and  myopia.  In  advanced  cases  the  protrusion  of  the  cornea 
is  very  evident,  and  the  apex  of  the  cone  may  become  nebulous.  In  some 
cases  vision  may  be  improved  by  concave  glasses  in  combination  with  a 
screen  having  a  narrow  slit  or  small  hole  in  it.  In  advanced  cases  opera- 
tion is  needed  :  (1)  Graefe's.  Shave  off  apex  without  entering  anterior 
chamber,  then  apply  mitigated  nitrate  of  silver  stick  to  the  raw  surface  to 
cause  ulceration  and  cicatrization.  (2)  Cut  off  apex  with  a  cataract  knife, 
enter  anterior  chamber,  leave  wound  to  unite  by  itself  or  use  sutures ;  use 
atropine  drops. 

Wounds  of  Cornea. — When  penetrating,  if  iris  is  prolapsed  push  it  back 
with  a  blunt  instrument,  and  order  atropine  drops  ;  if  iris  not  protruding, 
order  atropine  drops.  If  only  abraded,  still  order  atropine  drops.  Close 
the  eye  with  a  bandage  to  prevent  friction. 

Eyelids. — Blepharitis,  Stye,  Tarsal  Tumors,  Warty  Growths,  MoUuscum 
Contagiosum,  Ulcers,  Eodent  Ulcer,  Ptosis,  Ectropion,  Entropion,  Symble- 
pharon. 

Blephaeitis  (tinea  tarsi,  ophthalmia  tarsi,  sycosis  tarsi)  is  an  inflam- 
matory condition  of  the  edges  of  the  eyeUd,  which  commonly  attacks  the 
glands  and  the  foUicles  of  the  eyelashes.  It  varies  in  degree  from  mere 
congestion,  with  a  sticky  exudation,  to  chronic  or  subacute  inflammation, 
with  thickening  of  the  tissues,  excoriations,  and  even  pustules.  Treatment. 
— (1)  Keep  the  eyelids  clean  and  free  from  scabs  by  bathing  twice  daily 


EYELIDS.  303 

with  warm  water  or  warm  alkaline  lotion.  (2)  Apply  dilute  nitrate  of 
mercviry  ointment  twice  daily ;  in  severe  cases  pull  out  the  lashes  with 
epilation  forceps,  and  apply  nitrate  of  silver  to  the  edges  of  the  hds. 

Stye  (hordelum)  is  a  small  furunculus  at  the  margin  of  the  lid,  often 
very  painful.  Successive  crops  very  common.  Treatment. — Foment  with 
warm  water,  apply  bread-and-water  poultice  ;  pxincture  with  a  sharp  lancet 
as  soon  as  pointing  has  commenced. 

Tarsal  Tumor  (meibomian  cyst,  chalazion),  a  chronic  hypertrophy  of  a 
meibomian  gland,  occurs  as  a  small  hard  nodvde  from  1-4  mm.  in  diameter 
in  upper  or  lower  lids  ;  one  or  more  may  appear  at  the  same  time.  The 
skin  is  freely  movable  over  the  tumor,  which  is  hard,  and  not  painful.  If 
left  alone  it  generally  causes  thinning  of  the  conjunctival  tissue,  or  it  may 
point  through  the  surface.  Treatment. — Evert  the  lid  and  remove  by  in- 
cision from  the  conjunctival  surface.  "When  it  points  outward  it  is  better 
to  remove  through  the  skin  by  incision  parallel  to  margin  of  eyelid.  When 
thus  thoroughly  removed  it  does  not  recur.  When  only  incised  it  may 
remain  for  some  time. 

Warty  Growths  occasionally  appear  on  edges  of  lid.  Remove  freely 
with  scissors. 

MoLLUscuM  CoNTAGiosuM  often  appears  in  region  of  eyelids.  Consists  of 
one  or  more  hemispherical  elevations  of  from  one  to  six  mm.  in  diameter, 
containing  sebaceous  material  Treatment. — Divide  each  little  tumor  by 
vertical  incision,  and  squeeze  out  the  contents  by  means  of  the  thumb- 
nails apphed  to  the  bases  of  each. 

KoDENT  Ulcer  (epithelial  cancer,  rodent  cancer)  begins  as  a  slight  eleva- 
tion near  margin  of  eyelid  ;  this  is  followed  by  a  shallow  ulcer  with  slightly 
indurated  edges,  and  generally  a  brownish  incrustation.  Mostly  occurs 
in  persons  over  forty.  Progresses  slowly.  Seldom  cicatrizes.  Attacks 
aU  surrounding  tissues.  Neighboring  glands  not  enlarged.  Treatment. — 
Remove  all  the  diseased  structure  with  the  knife,  or  with  the  thermal 
cautery,  as  early  as  possible.  In  severe  cases  apply  chloride  of  zinc  paste 
in  addition,  after  removal  with  the  knife. 

SYPHnjTic  Ulcers  are  more  acute,  more  punched  out  in  appearance, 
have  less  indurated  margins,  and  are  more  amenable  to  treatment  than 
rodent  ulcer. 

Lupus  generally  occurs  in  younger  subjects,  and  in  other  parts  of  the 
face.     It  is  less  indurated  and  more  inflamed  than  rodent  ulcer. 

NiEvus,  often  congenital,  occasionally  occurs  on  the  eyelids,  may  be  con- 
fined to  the  skin,  or  may  involve  subcutaneous  tissue.  Treatment. — 1.  By 
electrolysis.     2.  By  subcutaneous  ligature.     3.  By  galvano-puncture. 

Ptosis  is  partial  or  complete  closiu-e  of  the  upper  eyelid.  Causes, 
various.  May  be  congenital  and  due  to  non-development  of  the  levator 
palpebrse  superioris  muscle.  May  be  due  to  paralysis  of  the  third  nerve, 
which  supphes  that  muscle.    May  be  the  result  of  iajm-y  to  that  muscle. 


304  GLAUCOMA. 

Treatment  varies  with  cause.  Graefe's  operation ;  make  incision  through 
akin  three  lines  above  the  margin  of  upper  lid,  and  extending  through  its 
whole  length,  and  expose  the  orbicularis  palpebrarum  muscle ;  seize  the 
muscle  with  forceps,  excise  a  portion  about  five  lines  in  width.  In  bringing 
edges  of  skin  together  pass  the  suture  through  the  cut  edges  of  the  muscle. 

Trichiasis,  ingrowing  of  the  eyelashes,  causing  irritation  of  the  globe. 
Frequently  caused  by  contraction  of  the  tissues  after  granular  Hds  and 
after  the  application  of  caustics  to  inside  of  Hds.  Treatment. — If  only  a 
few  lashes  are  turning  in,  these  may  be  removed  with  epilation  forceps. 
If  many  exist,  then  excision  of  the  hair-bulbs  should  be  performed  as  fol- 
lows :  Fix  the  lid  by  means  of  compressorium  forceps.  Make  two  incisions 
along  the  margin  of  the  lid,  one  on  each  side  of  the  row  of  eyelashes.  Cut 
deeply,  unite  the  incisions  at  each  end,  and  remove  the  piece  with  scissors. 
Sutures  not  required. 

Symblepharon  is  union  of  the  palpebral  and  ocular  conjunctivae  or  of 
the  margins  of  the  eyelids.  Caused  generally  by  burns,  as  with  molten 
lead,  or  caustic,  as  quicklime.  Treatment. — 1.  "When  the  edges  of  only  the 
lids  are  united,  or  when  a  probe  can  be  passed  beneath  the  united  con- 
junctivae ;  (a)  simply  divide  adhesions  with  knife,  and  keep  the  parts 
separated  by  means  of  oiled  lint ;  (6)  pass  a  strong  silk  ligature  beneath 
the  bands,  and  tie  tightly,  allowing  the  ligature  to  come  away  by  itself.  2. 
When  no  probe  can  be  passed  beneath  the  adhesions,  the  results  of  opera- 
tion are  less  satisfactory.  Separate  the  parts  by  incision,  and  then  dissect 
up  the  conjunctiva  on  both  sides,  and  endeavor  to  bring  the  flaps  thus 
formed  over  the  raw  surface  by  means  of  very  fine  silk  sutures  ;  still  keep 
the  ocular  and  palpebral  portions  apart  by  oiled  lint. 

Entropion. — Inversion  of  the  eyelids,  generally  caused  by  cicatrices 
after  caustics  such  as  Ume  or  nitrate  of  silver,  or  after  injury.  Treatment. 
— When  very  severe,  and  the  conjunctiva  is  much  contracted,  remove  the 
whole  row  of  eyelashes  as  recommended  for  trichiasis.  When  less  severe, 
perform  Streatfeild's  operation  of  grooving  the  cartilage. 

Ectropion. — Eversion  of  the  eyelid  ;  may  be  partial  or  entire.  Causes. 
— Contraction  after  injury  or  inflammation  of  the  parts  of  the  eyelid  which 
are  external  to  the  tarsal  cartilage  ;  or  contraction  of  cicatrices  of  the  face 
following  burns,  lupus,  etc.  Treatment. — Try  to  prevent  the  progress  of 
eversion  by  skin-grafting  on  to  woiinds  of  face.  When  permanently  estab- 
hshed  try  a  plastic  operation. 

Glaucoma  is  so  called  from  the  occasional  greenish  appearance  of  the 
pupillary  area.  The  pathognomonic  symptom  in  all  cases  of  glaucoma  is 
increased  hardness  or  "tension"  of  the  eyeball. 

Classification. — 1,  Acute;  2,  chronic ;  3,  secondary. 

Acute  Glaucoma. — Early  Symptoms. — Increased  tension.  Rapidly  in- 
creasing presbyopia.  Periodic  dimness  of  sight.  Halos  or  "rainbows" 
around  the  candle  or  other  lights.      Diminution  of  the  field  of  vision. 


IRIS.  305 

Laier  Symptoms. — Acute  pain.  Congestion  of  conjunctiva,  and  of  ciliary 
region.  Dilated  and  sluggish  pupil.  Rapid  impairment  of  vision.  Ten- 
sion of  globe  much  above  normal,  T  +  1  to  T  +  3  or  T  +  4.  There  may 
be  turbidity  of  the  vitreous  obscuring  the  fundus,  otherwise  the  oph- 
thalmoscope reveals — 1,  cupping  of  the  whole  of  optic  discs,  thS  edges 
being  abrupt ;  2,  probably  pulsation  of  the  retinal  vessels  ;  3,  tortuosity 
of  the  veins  ;  4,  small  hemorrhages  occasionally. 

Cheonic  Glaucoma  presents  the  same  symptoms  as  the  acute  form,  but 
in  a  modified  degree.  The  tension  of  the  globe  is  above  normal,  T  +  ^  to 
T  +  1  or  T  +  2,  but  the  increase  of  tension  is  less  rapid.  The  pain  is 
much  less,  and  may  be  absent  altogether. 

Secondary  Glaucoma  is  so  called  when  occurring  as  a  result  or  com- 
plication of  some  other  disease  or  injury  of  the  eye,  as  iridochoroiditis, 
needle  operation,  etc.     It  is  a  very  grave  symptom. 

Pathology. — What  is  the  cause  of  the  increased  tension?  Theory  1. 
Active  contraction  of  the  sclerotic.  2.  Excess  of  fluids  of  eye  from  in- 
creased supply  of  blood.     3.  Defective  removal  of  fluids  from  eye. 

The  region  of  the  ciliary  body  is  generally  found  to  have  undergone 
great  changes.  It  becomes  shrunken  to  half  its  natural  size,  its  muscular 
fibres  are  atrophied  and  sclerosed.  The  base  of  the  iris  is  found  to  be 
closely  applied  to  the  marginal  part  of  the  cornea.  The  ciliary  arteries  are 
enlarged.  The  changes  are  supposed  to  impede  the  escape  of  fluid  from 
the  anterior  chamber,  and  perhaps  from  the  vitreous  also.  The  glaucoma 
cup  is  caused  by  pressure  from  within.  The  lamina  cribrosa  which  forms 
the  floor  of  the  optic  disc,  being  the  weakest  part  of  the  capsule  of  the  eye, 
slowly  yields,  becomes  depressed  and  hollowed  out,  causing  atrophy. 

Treatment  for  Acute  Glaucoma. — Perform  iridectomy  without  delay. 
(1)  Make  incision  partly  in  coi'nea  and  partly  in  sclerotic.  (2)  Make  wound 
large  enough  to  allow  of  exit  of  one-fifth  of  iris.  (3)  Remove  iris  quite  up 
to  its  ciliary  attachment. 

Apply  leeches  to  eye,  and  warmth :  give  purgatives  and  derivatives 
internally. 

In  Chronic  Glaucoma. — First  try  action  of  eserine  drops,  with  local  de- 
pletion, and  calomel  and  opium  internally.  If  tension  continues  to  increase 
perform  iridectomy  as  in  acute  cases. 

Sclerotomy,  by  similar  incision  to  that  of  the  scleral  iridectomy,  but 
without  removing  a  portion  of  iris,  is  sometimes  practised.  Trephining 
the  sclerotic  behind  the  ciliary  region  has  also  been  introduced,  but  these 
are  both  less  efficient  than  iridectomy. 

Iris. — Iritis. — Causes. — Syphilis.  Rheumatism.  Inflamed  or  ulcerated 
cornea.     Injuries  as  in  operation  for  cataract. 

Symptoms. — (1)  Change  in  color ;  (2)  change  in  mobility ;  (3)  change 
in  vascularity ;  (4)  pain ;  (5)  impairment  of  vision  ;  (6)  photophobia  and 
lachrymation. 
20 


306  IRIS. 

(1)  Change  in  color  is  due  to  congestion,  and  to  effusion  of  lymph  and 
serum  into  the  texture  of  ii'is,  as  well  as,  in  part,  to  turbidity  of  aqueous. 
It  looks  blurred  and  "muddy." 

(2)  Change  in  mobility  is  indicated  by  the  pupU  not  responding  actively 
to  light,  but  becoming  sluggish  or  quite  inactive.  The  iris  becomes  more 
or  less  adherent  by  its  posterior  surface  to  the  capsule  of  lens,  constituting 
partial  or  complete  posterior  synechia  ;  when  partial  the  pupillary  margin 
becomes  jagged  under  atropine ;  when  complete,  the  pupil  cannot  be  dilated 
by  mydiiatics.  When  exudation  of  a  layer  of  lymph  takes  place  into  the 
pupillary  area  the  condition  is  termed  "occlusion," 

When  margin  of  pupil  is  adherent  to  lens  capsule  by  its  whole  circum- 
ference the  condition  is  termed  "exclusion." 

(3)  Increase  of  vascularity  in  the  cHiary  zone,  around  the  margin  of  the 
cornea,  generally  occurs  early,  and  the  conjunctival  vessels  are  generally 

.congested. 

(4)  Fain  of  a  neuralgic  character  in  and  aroimd  the  eye,  variable  in 
degree. 

(5)  Impairment  of  vision  is  always  more  or  less  marked,  may  be  owing 
to  turbidity  of  aqueous,  exudation  of  lymph  on  capsule  in  the  pupillary 
area,  impairment  of  accommodation  by  extension  of  inflammation  to  the 
ciliary  body. 

(6)  Photophobia  and  lachrymation  may  or  may  not  be  present. 

In  Syphilitic  Iritis,  which  only  occurs  in  secondary  syphilis,  there  is  ten- 
dency to  effusion  of  lymph,  and  formation  of  nodules  in  the  structure  of 
the  iris.  It  seldom  relapses  ;  it  is  often  symmetrical ;  pain  not  generally 
severe. 

In  Rheumatic  Iritis  there  is  little  tendency  to  effusion  of  lymph,  nodules 
never  formed,  generally  unsymmetrical,  although  both  eyes  may  suffer  in 
turns  ;  frequently  relapses  at  inteiTals  of  months  or  years  ;  congestion  and 
pain  often  severe  ;  sight  not  much  affected. 

Treatment. — (1)  Use  atropine  drops  (atropise  sulph.,  gr.  ij.  ad.  f  j.) 
three  times  daily  to  prevent  adhesions,  or  to  break  down  those  which  may 
have  recently  formed,  also  to  relieve  pain  and  congestion. 

(2)  If  pain  and  congestion  be  severe  apply  leeches  to  temple,  malar 
eminence,  or  septum  nasi ;  repeat  if  necessary ;  apply  blister  to  temple ; 
avoid  stimulants. 

(3)  For  syphilitic  iritis  employ  the  treatment  proper  for  secondary 
syphiHs.  For  rheumatic  iritis  give  alkalies,  iodide  of  potassium,  colchi- 
cum. 

(4)  Eest  the  eyes  ;  all  eye  work  to  be  discontinued  ;  order  a  shade  for 
both  eyes ;  darken  the  room,  or  bandage  the  affected  eye  vrith  a  pad  of 
cotton-wool,  especially  in  rheumatic  cases. 

(5)  Iridectomy  should  be  performed  (1)  in  those  cases  in  which  judi- 
cious local  and  internal  treatment  have  been  tried  "for  several  weeks  with- 


LACHRYMAL  APPARATUS.  307 

out  benefit ;  (2)  where  adhesions  exist  and  attacks  are  recurrent ;  (3)  when 
there  is  complete  exclusion  of  the  pupil. 

Operation  of  Iridectomy. — (1)  Separate  Hds  by  a  spring-stop  speculum. 
(2)  With  lance-shaped  knife  incise  sclerotic  one  line  from  corneal  margin, 
and  let  the  point  enter  anterior  chamber  just  in  front  of  iris,  keeping 
point  well  forward  to  avoid  wounding  the  lens.  (3)  Introduce  iris  forceps 
through  wound,  and  seize  iris  near  pupillary  margin ;  draw  this  out  through 
wound  and  cut  o£f  with  fine  scissors. 

Aetificiaii  Pupil  is  mostly  made  by  (1)  iridectomy ;  but  for  cases  in 
which  this  is  unsuitable  one  of  the  following  methods  may  be  adopted : 
(2)  by  using  a  broad  needle  and  hook  ;  (3)  by  iridodesis,  or  hgature  of  iris 
(Critchett's  operation) ;  (4)  by  division  of  iris  with  Wecker's  scissors  intro- 
duced into  anterior  chamber  (iridotomy). 

Prolapse  of  Iris  generally  follows  penetrating  and  incised  wounds  of 
cornea.  Treatment. — (1)  By  removal  of  prolapsed  portion  with  fine  scis- 
sors. (2)  By  compress  appHed  externally  over  closed  hds.  (3)  By  fre- 
quent puncturings  of  the  prolapsed  iris  with  a  fine  needle.  In  either  of 
these  methods  a  soothing  treatment  should  be  adopted.  Atropine  drops 
three  times  daily ;  bathing  with  belladonna  lotion.  After  some  days  a 
shade  should  be  worn,  and  the  eyes  carefully  watched. 

Coredialysis  is  a  partial  detachment  of  the  iris  from  its  cihary  border, 
forming  a  second  pupil.  It  is  generally  caused  by  a  sharp  blow.  Congeni- 
tal irideremia  (absence  of  iris)  is  occasionally  seen. 

Coloboma  of  the  Iris  (congenital  cleft)  appears  like  a  very  regular  result 
of  iridectomy  downward,  or  downward  and  inward  ;  usually  symmetrical ; 
variable  in  degree  ;  generally  associated  with  a  corresponding  defect  in 
the  choroid. 

Mydriasis  (dilatation  of  the  pupil)  is  a  derangement  which  may  be 
caused  by  disease  or  by  the  action  of  mydriatic  drugs,  e.g.,  glaucomatous 
tension  of  the  globe,  diseases  of  choroid  or  retina,  optic  atrophy,  paralysis 
of  third  nerve.  Mydriatics,  sulphate  of  ati'opia,  extract  of  belladonna,  sul- 
phate of  duboisine,  sulphate  of  daturine,  etc. 

Myosis  (contraction  of  pupil)  may  be  caused  by  spasmodic  action  of  the 
circular  fibres  of  iris,  loss  of  power  of  radiating  fibres  of  iris,  hypersesthesia 
of  retina,  affection  of  spino-sympathetic  filaments  which  supply  the  radiat- 
ing fibres  of  iris,  myotic  drugs,  e.g.,  Calabar  bean,  sulphate  of  eserine,  ni- 
trate of  pilocarpine. 

Lachrymal  Apparatus. — Overflow  of  tears  (lachrymation,  epiphora, 
stillicidium)  is  caused  by  excessive  secretion,  or  by  some  defect  in  the 
lachrymal  apparatus  which  prevents  the  escape  of  the  tears.  This  defect 
may  exist  (1)  at  the  punctal  achrymaha,  which  may  be  displaced  or  ob- 
structed; (2)  in  the  canaliculi,  which  may  be  obstructed  by  stricture  near 
the  sac  or  by  foreign  body  ;  (3)  in  the  lachrymal  sac  or  nasal  duct. 

Inflammation  of  the  Lachrymal  Sac  is  very  common  ;  generally  caused 


308  OPTIO   NERVE. 

by  stricture  of  the  nasal  duct.  Symptoms. — Lachrymation,  presence  of  a 
tumor  (mucocele)  at  the  inner  canthus,  which  may  often  be  emptied  by 
pressure  with  the  finger,  the  contents  passing  upward  through  canalicuh, 
or  downward  through  nasal  duct.  The  contents  of  the  sac  vary  according 
to  the  character  of  the  inflammation.  At  first  it  consists  of  viscid  muciis, 
which  may  remain  a  long  time,  or  may  become  semi-purulent;  in  more 
acute  inflammation  there  is  abundant  suppuration  with  swelling  of  sur- 
rounding parts,  and  pointing  either  through  the  skin,  when  a  lachrymal 
fistula  is  estabUshed,  or  through  the  conjunctiva  near  the  caruncle.  Treat- 
ment.— 1.  Slit  up  the  canahculus,  and  so  give  free  exit  to  contents  of  sac. 
This  may  be  done  upon  Critchett's  director,  or  by  passing  a  "Weber's  canal- 
iculus knife,  or  by  a  pair  of  delicate  scissors.  2.  Endeavor  to  cure  the 
stricture  of  the  nasal  duct  by  passing  a  lachrymal  probe  every  third  day 
until  lachrymation  ceases.  Various  kinds  of  lachrymal  probes  are  used,  as 
Bowman's,  Couper's,  Weber's. 

Fistula  of  lachrymal  sac  frequently  occurs  in  acute  inflammation — a 
small  tortuous  sinus  between  the  sac  and  the  skin,  from  which  a  contin- 
uous oozing  of  the  tears  on  to  the  cheek  takes  place.  Treatment. — (1) 
Cure  the  stricture  and  restore  the  mucous  membrane  to  a  healthy  condi- 
tion. (2)  If  necessary,  pare  the  edges  of  fistulous  opening,  and  bring  to- 
gether by  fine  suture. 

Lachrymal  Gland. — Hypertrophy,  acute  and  chronic  inflammation,  ab- 
scess, fistula,  cysts,  sarcoma.  Removal  sometimes  required  for  disease  or 
for  obstinate  cases  of  lachrymation.  Operation.  —  Make  incision  below 
upper  and  outer  third  of  the  orbital  ridge  through  skin  and  the  fascia  : 
feel  for  gland  with  finger,  seize  with  hooked  forceps,  draw  forward,  sever 
vnth  knife,  do  not  close  wound  till  hemorrhage  has  ceased. 

Optic  Nerve. — Diseases  :  Neuritis  ;  Atrophy. 

Optic  Neueiti's  may  extend  from  the  brain  to  the  retina  (descending) ; 
may  commence  at  the  optic  disc  (papillitis)  and  thence  pass  along  the 
nerve  (ascending).  When  the  disc  is  affected  there  may  be  (a)  simple  con- 
gestion ;  (&)  congestion  with  swelling,  which  renders  the  outline  of  the 
disc  more  or  less  obscure.  Causes. — Cerebral  tumor,  meningitis,  syphilis, 
albuminuria,  lead-poison,  wound  of  cornea,  hypermetropia.  The  sight  is 
affected  in  proportion  to  the  change  in  the  optic  nerve  fibres.  There  may 
be  lessened  acuteness  of  vision,  Umitation  of  field  of  vision,  altered  color 
perception.  Treatment. — Endeavor  to  find  the  cause  of  the  malady  and 
treat  this.  Rest  the  eyes.  In  cases  where  syphilis  is  a  known  cause,  give 
a  prolonged  but  mild  course  of  mercury  and  iodide  of  potassium.  When 
syphilis  is  the  probable  cause,  give  iodide,  and  in  the  early  stage  give  mer- 
cury also.     In  strumous  cases,  pursue  tonic  treatment. 

Atrophy  of  Optic  Nerve  may  commence  without  any  visible  inflamma- 
tion of  disc  (primary),  or  may  follow  as  a  result  of  papUHtis.  The  optic 
disc  varies  in  appearance  from  slight  paUor  to  bluish-white.     The  vessels 


EETINA.  809 

» 
may  be  of  normal  size,  or  may  be  mucli  atrophied.     Treatment. — Give  qui- 
nine and  iron  internally.     Phosphorus,  nitrate  of  silver  and  strychnine  are 
each  sometimes  employed.     Try  the  interrupted  voltaic  current. 

Retina. — The  healthy  human  retina  is  so  transparent  during  Hfe  that 
it  is  hardly  seen  with  the  ophthalmoscope.  The  vessels  of  the  retina  are 
seen  radiating  from  the  optic  disc.  Inflammatory  and  other  deposits  in 
the  retina  are  also  seen  when  present.  The  chief  diseases  of  the  retina 
are,  Hyperaemia,  Ketinitis,  Detachment,  Embohsm  of  the  Central  Artery^ 
Ghoma,  Cysts. 

Hyperemia. — Generally  caused  by  overwork,  especially  if  patient  be 
ametropic.  Fundus  looks  too  red,  and  optic  disc  has  a  pinkish,  flushed 
appearance.  Treatment. — Functional  rest,  local  depletion  by  leeches  or 
bhster  if  necessary.     Correction  of  ametropia  by  use  of  spectacles. 

Ketinitis. — (a)  Syphilitic;  (b)  albuminuric;  (c)  apoplectic;  (d)  pig- 
mented. 

Syphilitic  Ketinitis. — One  of  the  many  secondary  symptoms  of  syphiha 
— generally  occurring  between  six  and  eighteen  months  after  infection — 
occurs  in  inherited  as  well  as  in  acquired  syphiHs.  Ophthalmoscope  shows 
a  grayish  white  haze  around  optic  disc,  patches  of  yellowish  white  exuda- 
tion over  the  fundus,  generally  more  or  less  choroiditis,  generally  more  or 
less  turbidity  of  vitreous.  Treatment. — Functional  rest  of  eyes,  general 
treatment  for  secondary  syphihs. 

Albuminuric  Ketinitis  (Nephritic  K.)  may  come  on  gradually  with  the 
advance  of  kidney  disease  ;  may  be  dependent  on  uraemia  and  occur  in  the 
later  stages  of  kidney  disease.  May  be  caused  by  temporary  albuminuiia, 
as  in  that  which  occasionally  occurs  during  pregnancy.  In  early  stage 
sight  may  be  unaffected.  Ophthalmoscope  shows  a  dull  gray  haze  in  cen- 
tral region  of  retina  due  to  oedema,  generally  a  few  small  patches  of  hemor- 
rhage scattered  over  fundus.  Optic  disc  may  be  also  swollen.  In  ad- 
vanced stage  sight  greatly  affected  in  one  or  both  eyes.  Central  region 
occupied  by  numerous  dots,  spots,  or  patches  of  an  opaque  white  substance 
grouped  around  the  yellow  spot.  Hemorrhages  are  frequent,  and  usually 
have  a  striated  appearance.  Optic  nerve  sometimes  inflamed  (neuroreti- 
nitis).  Prognosis  must  be  guarded.  Treat  disease  of  kidneys.  Rest  and 
protect  eyes  by  cobalt-blue  glasses. 

Retinitis  Apoplectica. — From  sudden  hemorrhage  from  a  retinal  vessel, 
from  disease  of  vessels,  or  of  heart. 

Retinitis  Pigmentosa. — Characterized  by  a  peculiar  deposit  of  dark  pig- 
ment— varying  in  pattern — usually  commences  at  the  peripheiy  of  the 
fundus,  and  gradually  approaches  the  centre.  Optic  disc  of  a  pale  yellow 
color.  Often  associated  with  posterior  polar  cataract.  Often  occurs  in 
several  members  of  the  same  family.  Prognosis  bad.  May  remain  station- 
ary.    May  go  on  from  bad  to  worse. 

Detachment  of  Retina  may  be  partial  or  entire.     Causes :  (a)  elonga- 


310  REFRACTION. 

tion  of  coats  of  eyeball  as'  in  extreme  myopia  ;  (b)  ditninution  of  vitreous ; 
(c)  hemorrhage  or  serous  exudation  between  retina  and  choroid  ;  (d)  tu- 
mors of  choroid.  Symptoms. — By  direct  examination  the  detached  portion 
appears  as  a  bluish-gray  film  bounded  by  a  sharp  line.  The  vessels  traced 
fi'om  disc  give  a  sudden  bend  at  the  line  of  detachment.  The  detached 
portion  is  seen  to  be  pushed  forward,  and  the  vessels  upon  it  are  tortuous, 
small,  and  of  dark  color.  The  field  of  vision  is  Hmited.  Prognosis  is  un- 
favorable. 

Glioma,  a  small  round-celled  growth  proceeding  from  the  granular 
layers  of  the  retina,  occurring  generally  in  very  young  children.  It  is  seen 
as  a  ghstening  white  substance  at  the  bottom  of  the  eye,  and  if  allowed  to 
remain,  it  rapidly  spreads  along  optic  nerve  to  the  braia,  and  to  the  sur- 
rounding structures  within  the  orbit.  Secondaiy  deposits  may  occur. 
Treatment. — Early  excision  of  globe. 

Refraction  of  the  eye  signifies  the  influence  exercised  by  the  trans- 
parent media  upon  rays  of  hght  entering  it. 

Emmetkopia  signifies  normal  refraction. 

Ametropia  signifies  abnormal  refraction,  and  may  be  divided  into  (1) 
myopia  ;  (2)  hypermetropia  ;   (3)  astigmatism. 

Emmetkopia  is  that  condition  of  refraction  in  which  rays  from  distant 
objects,  and  which  are  practically  parallel,  come  to  a  focus  upon  the  retina 
when  the  eye  is  at  rest,  that  is,  when  accommodation  is  relaxed.  The  Em- 
metropic eye  cannot  see  near  objects  without  increasing  the  convexity  of 
the  crystalline  lens,  because  the  rays  from  near  objects  are  divergent,  and 
would  therefore  focus  behind  the  retina.  This  change  of  shape  in  the  lens 
is  effected  by  the  ciliaiy  muscle,  and  is  called  accommodation. 

The  farthest  distance  of  distinct  vision  in  any  state  of  refraction  is 
called  the  far-point,  the  shortest  distance  of  distinct  vision  is  the  near-point. 
The  near-point  and  ihe  far-point  are  found  by  means  of  test  types.  Those 
of  Snellen  and  Jiieger  are  in  common  use.  The  distance  between  the  near- 
point  and  the  far-point  is  called  the  range  or  amplitude  of  accommodation. 
It  is  the  distance  over  which  the  eye  has  command  by  means  of  its  accom- 
modation. 

Accommodation,  as  we  have  seen,  depends  upon  the  contractility  of  the 
cihary  muscle,  and  upon  the  elasticity  of  the  crystalline  lens.  Now,  as  age 
advances,  the  ciliary  muscle  gradually  loses  its  contractility,  and  the  lens 
its  elasticity.  So  that  in  emmetropia  the  near-point  gradually  recedes 
from  the  eye.  This  recession  commences  at  about  the  age  of  ten.  Thus 
at  the  age  of  ten  years  the  amplitude  of  accommodation  is  equal  to  a  lens 
of  14  D,  and  the  distance  of  the  near-point  from  the  eye  is  7  centimetres ; 
at  fifteen  years  the  distance  is  8  ctm.  ;  at  twenty  years  it  is  10  ctm.  ;  at 
thirty  years  it  is  14  ctm.  ;  at  forty  years  it  is  22  ctm. ;  at  fifty  years  it  is 
40.5  cm. 

The  emmetropic  eye,  therefore,  can  read  No.  6  of  Snellen's  test  types 


BEFRACTION. 


311 


at  the  distance  of  six  metres  without  the  aid  of  either  convex  or  concave 
lenses  (V=f)  at  all  ages.  It  can  read  No.  1  of  Snellen's  test-types  for 
reading  as  near  as  7  centimetres  up  to  the  tenth  year  of  age,  but  after  that 
time  there  is  a  gradual  recession  of  this  near-point.  At  the  age  of  forty 
years  the  near-point  is  22  ctm. 

Pkesbyopia  (Old  Sight)  is  that  condition  in  which  the  near-point  has  so 
far  receded  as  to  cause  discomfort  in  reading  and  fine  work.  This  distance 
is  about  22  ctm.  (8  inches).  In  the  normal  eye  this  distance  {see  Emmeteo- 
pia)  is  reached  at  about  forty  years,  so  that  after  that  age  all  fine  work, 
such  as  reading,  needlework,  etc.,  must  be  held  at  more  than  22  ctm.  from 
the  eye.  This  inconvenience  is  easily  overcome  by  prescribing  convex 
lenses  to  be  worn  for  reading  and  fine  work.  The  following  table  will 
show  the  strength  of  the  lens  required  by  the  normal  eye  at  different  ages, 
to  correct  for  presbyopia  : 


Age. 

40 
45 
50 
55 
60 
65 
70 
75 
80 


Strength  of  Spherical  Convex 
Lens  in  Dioptres. 

0 

1 

2 

3 

4 

4.5 

5.5 

6 

7 


In  hypermetropia  presbyopia  comes  on  earlier  than  in  emmetropia,  be- 
cause the  hypermetropia  has  to  be  neutralized  before  any  accommodation 
is  available  for  near  vision.  Thus,  suppose  a  hypermetrope  of  2  diopti-es, 
what  strength  of  lens  would  be  required  to  correct  his  near  vision  at  the  age 
of  fifty  ?  He  wiU  require  first  2  D  to  correct  the  hypermetropia,  and,  by  the 
above  table,  we  see  that  2  D  would  be  the  strength  required  if  he  were  em- 
metropic. Therefore,  2  -f  2  =  4D,  or  let  x  be  the  amount  of  hypermetropia 
expressed  in  dioptres,  and  a;'  the  strength  of  lens  required  according  to 
age,  then  xD  +  x^  D  will  be  the  strength  of  the  spectacles  required  for 
near  vision.  In  myopia  presbyopia  comes  on  later  than  in  emmetropia, 
because  for  the  same  amount  of  accommodation  the  near-point  is  always 
nearer  than  in  the  normal  eye.  In  very  high  degrees  of  myopia  (over  4.5 
dioptres)  the  patient  will  never  become  so  presbyopic  as  to  require  convex 
glasses  for  near  vision,  because  in  a  state  of  repose  the  eyes  are  adapted 
for  a  shorter  distance  than  22  ctm.  He  may,  however,  require  concave 
glasses  for  near  as  well  as  for  distant  vision  (see  Myopia).  Suppose  a  myope 
of  3  D,  sixty  years  old,  what  spectacles  would  he  require  ?    We  see  by  the 


312  EEFEACTION. 

table  that,  if  emmetropic,  he  would  require  4  D,  and  we  know  that  he  has 
myopia  =— 3  D.  Therefore  +4— 3=-f-l  D  will  be  the  strength  of  spec- 
tacles required  for  near  vision. 

Myopia  (Short  Sight)  is  that  condition  of  refraction  in  which  parallel 
rays  come  to  a  focus  in  front  of  the  retina,  the  eye  being  at  rest.  Symp- 
toms.— Patient  cannot  see  distant  objects  clearly,  and  if  told  to  read  small 
print  (No.  1  of  Snellen's  test  types)  will  hold  it  within  the  distance  of  his 
far-point  from  the  eye.  Vision  improved  by  concave  sj)herical  lenses, 
made  worse  by  convex  lenses.  Retinoscopy  reveals  a  shadow  which  passes 
in  the  same  direction  as  the  reflected  light.  Ophthalmoscopy.— 1.  By  di- 
rect examination  with  mirror  alone,  image  of  vessels  of  fundus  seen  at  dis- 
tance from  eye,  and  moves  in  the  opposite  direction  to  the  observer's  head 
when  the  latter  is  moved  from  side  to  side.  2.  By  indirect  examination, 
the  optic  disc  appears  smaller  than  in  emmetropia,  and  appears  to  increase 
in  size  on  withdrawing  the  lens  used.  3.  By  direct  examination,  when  the 
instrument  is  held  close  to  the  patient's  eye  the  retinal  vessels,  optic  disc, 
and  other  details  of  the  fundus  cannot  be  clearly  seen  without  the  inter- 
vention of  a  concave  lens,  the  strength  of  the  lens  required  for  this  pur- 
pose being  a  measure  of  the  degree  of  myopia.  In  many  cases  a  crescentic 
patch  of  yellowish  white  appearance  {myopic  crescent)  is  seen  on  the  outer 
side  of  the  oj^tic  disc  ;  this  is  caused  by  atrophy  of  the  choroid.  In  high 
degrees  of  myopia  other  patches  of  choroidal  atrophy  are  often  seen. 
Choroidal  hemorrhages  and  hemorrhages  into  vitreous  occasionally  oc- 
cur. Causes. — Too  great  length  of  globe.  Too  great  curvature  of  cornea. 
Too  high  refractive  power  of  media  of  eye.  Hereditary  tendency.  Pro- 
longed use  of  eyes  in  looking  at  close  objects.  Treatment. — Having  ascer- 
tained accurately  the  degree  of  myopia,  order  spectacles  to  be  worn.  1. 
To  give  clear  vision  of  object  at  a  distance  (No.  6  to  60  Snellen's  at  6  me- 
tres). 2.  To  enable  the  patient  to  read  small  print  (No.  1  Snellen)  at  the 
same  distance  as  an  emmetrope.  In  all  cases  of  myopia  below  6  or  7  diop- 
tres, where  the  accommodation  is  good,  the  glasses  which  exactly  correct 
the  myopia  should  be  used  for  near  and  for  distant  vision.  They  should 
be  worn  constantly.  In  most  cases  where  the  myopia  is  higher  than  7  D, 
and  in  all  cases  where  the  accommodation  is  feeble,  two  kinds  of  spectacles 
must  be  worn  :  one  pair  for  distance,  equal  in  strength  to  the  degree  of 
myopia,  another  pair  for  near  vision  of  lower  power.  The  required  strength 
of  these  is  found  in  the  following  manner  (Bonders) :  From  the  lens  which 
exactly  neutralizes  the  myopia  deduct  the  strength  of  a  lens  whose  focal  length 
is  equal  to  the  distance  at  which  we  loish  the  patient  to  work.  Thus,  suppose 
a  myope  of  10  D  wishing  to  read  No.  1  Snellen  at  40  ctm.  From  10  D 
deduct  the  lens  whose  focal  length  is  40  ctm.,  viz.,  2.50  D;  then  —  10-f- 
2.50=— 7.50  D,  and  ^7.50  D  is  the  strength  of  spectacle  required.  In 
prescribing  for  patients  over  forty,  proper  allowance  must  be  made  for 
presbyopia  {see  Presbyopia). 


KEFEACTION.  313 

Hypermetropia  is  that  condition  of  refraction  in  which  parallel  rays 
come  to  a  focus  behind  the  retina — the  eye  being  at  rest. 

Causes. — 1.  Most  commonly  the  axis  of  the  eye  is  too  short.  2.  The 
curvature  of  the  comea  or  of  the  surface  of  the  lens  may  be  insufficient. 
3.  The  refractive  index  of  the  media  may  be  too  low.  The  disease  is  fre- 
quently hereditary. 

Symptoms. — Since  rays  from  a  distant  object  (parallel  rays)  come  to  a 
focus  behind  the  retina,  it  follows  that  rays  from  a  near  object  {divergent 
rays)  will  be  focussed  still  further  behind  the  retina,  and  therefore  a  hyper- 
metrope  is  unable  to  see  anything  clearly,  either  distant  or  near,  without 
using  accommodation.  If  therefore  the  hypermetropia  be  slight,  and  the 
accommodation  powerful,  there  will  be  no  inconvenience,  either  for  near 
or  distant  vision.  But  if  the  accommodation  is  failing,  as  it  always  does 
from  age,  and  as  it  frequently  does  from  disease,  the  patient  cannot  see 
near  objects  for  long  together  without  aching  pains  or  sense  of  fatigue  in 
the  eyes,  combined  with  dimness  of  vision.  In  high  degrees  of  hyperme- 
tropia the  greater  part  of  the  accommodation  is  required  for  distant  vision, 
and  the  patient  is  never  able  to  see  near  objects  clearly.  The  symptoms 
therefore  vary  with  the  degree,  and  become  more  manifest  as  age  advances. 
Hypermetropia  is  frequently  an  indirect  cause  of  squint  (see  Strabismxts). 
The  objective  symptoms  are  as  follows : 

1.  Keratoscopy  reveals  a  shadow  which  passes  in  the  opposite  direction 
to  that  of  the  reflected  Ught. 

2.  Ophthalmoscopy. — Direct  method  at  a  good  distance  from  the  eye 
shows  the  image  of  vessels  of  fundus,  and  this  image  moves  in  the  same 
direction  as  the  observer's  head  when  the  latter  is  moved  from  side  to  side. 

Indirect  method  shows  size  of  disc  to  diminish  on  withdrawing  the  lens 
from  patient's  eye. 

Direct  method. — When  oblique  mirror  is  used  close  to  the  patient's  eye, 
and  the  accommodation  both  of  patient  and  observer  relaxed,  no  clear  de- 
tail of  fundus  can  be  made  out  without  the  aid  of  a  convex  lens.  The 
stren^-th  of  the  lens  thus  required  to  make  quite  clear  the  detail  of  fundus 
gives  an  exact  estimate  of  the  degree  of  hypermetropia. 

3.  By  means  of  Test-types  and  Test-glasses. — See  if  patient  can  read  Nos. 
6  to  100  Snellen  at  6  metres.  Then,  if  he  can  read  the  same  as  well  or 
better  with  a  convex  glass,  the  highest  glass  with  which  he  gets  the  best 
vision  is  a  measure  of  his  manifest  hypermetropia.  In  children,  and  in  all 
cases  where  spasm  of  the  ciliary  muscle  is  suspected,  it  is  necessary  to 
paralyze  the  accommodation  by  atropine  drops,  in  order  to  obtain  the  latent 
as  well  as  the  manifest,  that  is,  the  total  hypermetropia. 

Treatment. — Having  found  the  degree  of  hypermetropia,  order  specta- 
cles to  be  worn  as  follows  :  1.  In  children  and  young  adults  order  the  con- 
stant use  of  glasses  both  for  near  and  distant  vision  ;  the  strength  of  these 
should  be  equal  to  all  the  manifest  hypermetropia  plus  half  the  latent. 


314  KEFRACTION. 

Patient  may  complain  of  inconvenience,  but  should  persevere.  2.  In  per- 
sons over  forty  years  of  age  order  glasses  as  directed  under  Presbyopia 
(see  Presbyopia). 

Astigmatism  is  Regular  or  Irregular. 

Kegulab  Astigmatism  is  that  condition  in  which  the  refraction  is  dijBfer- 
ent  in  different  meridians  of  the  same  eye ;  the  two  principal  meridians 
being  always  at  right  angles  to  each  other. 

Irregular  Astigmatism  is  that  condition  in  which  there  are  different  de- 
grees of  refraction  in  different  parts  of  the  various  meridians.  Regular 
Astigmatism  may  exist  in  five  different  forms. 

1.  Simple  Myopic. — One  meridian  emmetropic,  and  the  other  myopic. 

2.  Simple  Hypermetropic. — One  meridian  emmetropic,  the  other  hyper- 
metropic. 

3.  Compound  Myopic. — Both  meridians  myopic,  one  more  than  the 
other. 

4.  Compound  Hypermetropic.  —  Both  meridians  hypermetropic,  one 
more  than  the  other. 

5.  Mixed. — One  meridian  myopic,  the  other  hypermetropic. 

Causes. — Chiefly  tmequal  curvature  of  cornea,  perhaps  irregularity  of 
lens  also.  Symptoms  vary  with  the  kind  and  the  degree  of  astigmatism. 
The  lower  forms  often  pass  unheeded  until  rather  late  in  Hfe,  The  higher 
forms  cause  such  fatigue  and  distress  that  the  eyes  are  disqualified  from 
prolonged  exertion.  Astigmatism  must  always  be  suspected  when  by  test- 
ing with  spherical  lenses  the  patient  cannot  be  made  to  read  Nos.  6  or  9 
Snellen  at  6  metres  (the  fimdus  being  otherwise  healthy).  When  astigma- 
tism is  suspected,  proceed  to  examine  each  eye  carefully  as  follows : 

1.  Rhinoscopy. — The  intensity,  direction,  and  velocity  of  shadow  will 
indicate  the  kind  of  error  in  each  meridian. 

2.  Ophthalmoscopy. — By  indirect  examination  the  optic  disc  appears 
oval  instead  of  circular,  and  by  withdrawing  the  mirror  used  away  from 
the  patient's  eye  the  disc  appeai-s  to  change  its  shape.  By  direct  examma- 
tion,  the  mirror  being  held  close  to  patient's  eye,  the  vessels  of  the  different 
meridians  may  be  seen  with  lenses  of  different  powers,  the  difference  be- 
tween the  powers  of  the  lenses  thus  used  being  an  exact  measure  of  the 
degree  of  astigmatism. 

3.  Place  patient  at  distance  of  six  metres  from  Snellen's  test-types,  and 
■with  spherical  lenses  correct  the  ametropia  as  far  as  possible.  Then  rotate 
in  front  of  the  correcting  lens  a  stenopaic  slit ;  by  this  means  the  two  prin- 
cipal meridians  will  be  found,  and  must  be  corrected  seriatim.  The  differ- 
ence of  power  between  the  lenses  which  correct  these  two  meridians  is  an 
exact  measure  of  the  degree  of  astigmatism.  The  same  object  may  be  ef- 
fected by  the  use  of  cylindrical  glasses  without  the  slit. 

4.  An  excellent  instniment  for  finding  the  two  meridians  is  Tweedy's 
Optometer  (see  Lancet,  October  28,  1876). 


STEABISMUS.  315 

"Whatever  means  be  employed  in  diagnosis,  cylindrical  lenses  shoidd 
be  prescribed  which  fully  correct  the  astigmatism.  The  patient  may  not 
be  able  to  see  very  much  at  first,  but  by  the  continued  use  of  spectacles  the 
vision  wiU  generally  improve. 

Strabismus  (Squint). — The  visual  Hne  is  the  axial  line  joining  the 
centre  of  the  object  observed,  with  the  centre  of  its  image  on  the  yellow 
spot  of  the  retina.  Deviation  of  the  eye  from  the  visual  line,  so  that  the 
image  does  not  fall  on  the  yellow  spot,  but  on  some  other  part  of  the  retina, 
is  called  squint.  This  deviation  may  produce  double  vision — diplopia — 
when  the  image  formed  by  the  squinting  is  usually  fainter  than  that  of  the 
other  eye,  and  is  called  the  false  image.  When  the  false  image  appears 
on  the  same  side  of  the  true  image  as  the  deviating  eye,  the  diplopia  is 
termed  homonymous,  when  on  the  opposite  side  the  diplopia  is  crossed. 
The  greater  the  deviation  of  the  eye  the  fainter  the  image  appears,  as  it 
falls  more  upon  the  periphery  of  the  fundus.  Patients  learn  to  disregard 
the  false  image,  and  so  to  use  one  eye  at  a  time  or  one  eye  only.  Causes 
of  Squint. — (a)  Ametropia;  (6)  affection  of  ocular  muscles,  as  over-action, 
weakness,  paralysis  ;  (c)  disuse  of  eye.  Chief  kinds  are  internal  and  ex- 
ternal. 

Internal  Stkabismus  (Convergent). — Very  common,  generally  caused  by 
hypermetropia.  In  hypermetropia  the  patient  is  obliged  to  use  accommo- 
dation in  order  to  see  even  distant  objects.  Now  accommodation  is  always 
accompanied  by  convergence,  and  when  a  near  object  has  to  be  seen,  the 
accommodation  and,  consequently,  the  convergence  used,  are  so  great  that 
the  eyes  deviate  internal  to  the  visual  line,  so  that  the  image  does  not  fall 
upon  the  yeUow  spot,  and  is  therefore  not  distinct.  Patient  then  fixes  one 
eye  upon  the  object,  i.e.,  causes  it  to  move  in  the  direction  of  the  visual 
Hne  whilst  the  other  eye  still  deviates.  The  amount  of  deviation  is. meas- 
ured by  the  distance  between  two  vertical  lines,  one  bisecting  the  pupil, 
the  other  bisecting  the  eyelids.  Diagnosis. — In  well-marked  cases  let  pa- 
tient look  steadily  at  the  tij)  of  index  finger  placed  about  a  foot  in  front  of 
eyes,  then  screen  each  eye  successively,  and  watch  the  eye  thus  screened. 
The  squinting  eye  makes  a  decided  movement  toward  the  visual  line  when 
the  working  eye  is  covered,  but  the  working  remains  quite  stationary  when 
the  squinting  is  screened.  In  less  marked  cases  the  diagnosis  is  more 
difficult.  Take  patient  into  dark  room  and  direct  him  to  look  steadily  at 
lighted  candle  at  distance  of  ten  feet  without  moving  his  head.  Place  a 
piece  of  red  glass  in  front  of  one  eye,  then  if  diplopia  be  present  the  image 
of  this  eye  will  be  red  and  that  of  the  other  eye  of  normal  color.  The 
distance  of  these  images  apart  and  their  relative  position  gives  the  charac- 
ter of  the  deviation— homonymous  diplopia  indicating  convergent,  and 
crossed  diplopia  indicating  divergent  strabismus.  Treatment. — 1.  If  the 
patient  be  hypermetropic,  if  squint  be  slight  and  of  recent  date,  and  if 
vision  be  good  in  both  eyes,  try  the  effect  of  well-fitting  convex  spectacles 


316  STRABISMUS. 

for  one  or  two  months.  2.  Perform  tenotomy  of  the  internal  rectus  of  one 
or  both  eyes.  Both  eyes  generaDy  require  to  be  operated  on.  Operation. 
— Separate  lids  by  stop-speculum,  let  assistant  tm-n  eye  outward  by  for- 
ceps, with  toothed  forceps  pinch  fold  of  conjunctiva  between  cornea  and 
caruncle,  with  squint- scissors  cut  through  this  and  through  the  capsule  of 
Tenon,  pass  squint-hook  beneath  the  tendon  from  below  and  cut  it  through 
between  hook  and  globe,  pass  in  the  squint-hook  a  second  time  to  be  quite 
sure  that  the  tendon  is  divided ;  suture  for  conjunctival  wound  is  not  gen- 
erally used. 

ExTEENAii  Stkabismus  (Divergent)  is  the  result  of  weakness  of  the  inter- 
nal rectus ;  commonest  in  myopia  ;  occasionally  occurs  in  hypermetropia ; 
sometimes  occurs  in  a  blind  eye  ;  may  follow  tenotomy  of  internal  rectus 
where  too  much  subconjunctival  tissue  has  been  divided  ;  common  in  par- 
tial or  complete  paralysis  of  the  third  nerve.  Diagnosis,  the  same  as  for 
internal  strabismus.  Treatment. — If  resulting  from  paralysis,  try  and  find 
the  cause  of  paralysis  and  treat  this  ;  if  not  from  paralysis,  perform  tenot- 
omy of  the  external  rectus,  and  if  necessary  also,  at  the  same  sitting,  per- 
form the  operation  for  readjustment  or  advancement  of  the  internal  rectus. 
This  is  done  in  various  ways,  and  consists  of  separation  of  the  muscle  from 
its  insertion  into  sclerotic,  and  bringing  it  further  forward  on  sclerotic  by 
means  of  sutures  passed  through  the  muscle  and  attached  to  conjunctiva 
close  to  cornea. 


List  op  Works  Consulted  in  the  Foregoing  Notes. 

Wecker  and  Landolt— "  Traite  Complet  d'Ophthalmologie,"  1879. 

Wecker — "  Chirurgie  Oculaire." 

Bonders — "Anomalies  of  Accommodation  and  Refraction." 

Pagenstecher  and  Geath — "Atlas  of  the  Pathological  Anatomy  of  the  Eyeball." 

Graefe  and  Saemisch — "  Handbuch  der  Augenheilkunde." 

Soelberg  Wells — "  Diseases  of  the  Eye." 

Nettleship — "  Diseases  of  the  Eye." 

Lawson — "  Diseases  and  Injuries  of  the  Eye.'* 

Brudenell  Carter — "  Diseases  of  the  Eye. 

Gowers — ' '  Medical  Ophthalmoscopy. " 

Streatfeild — Chapter  on  "  Ophthalmic  Surgery  "  in  Erichsen's  "  Surgery." 


INDEX    OF    NAMES. 


(See  also  end  of  '*  J^otes  on  Ophthalmic  Surgery") 


Abbe,  280 

Abrath,  103 

Adams,  115,  230,  283,  285 

AUarton,  172 

Alibert,  56 

Allingham,  60 

Amussat,  60 

Anel,  15 

Annandale,  230 

Antyllus,  15,  17 

Araott,  42 

Ayres,  29 


Baker,  Morrant,  14,  37,  42,  199,  235 

Barker,  A.,  21 

Bar  well,  59,  116,  158,  190 

Bassereau,  219 

Baumler,  288 

Beck,  Marcus,  160,  161 

Bellocq,  76 

Bernard,  1 

Bickerateth,  207 

Bigelow,  32,  170,  174,  175 

BUlroth,  37,  38,  54,  98,  100,  109,  112,  144, 

153,  200,  201,  204,  207,  218,  232 
Birkett,  130,  189 
Bloxam,  64 
Brandeis,  183 
Brasdor,  15,  17 
Brodie,  28,  35 
Brou,  103 
Brown,  G.,  57 
Brown -Sequard,  232 
Browne,  Baker,  192 
Browne,  Lennox,  169,  183 


Brunei,  169 

Bryant,  22,  51,  92,  111,  120, 135,  185,  194, 

206,  269 
Buchanan,  172 
Bumstead,  289 
Burdon-Sanderson,  145 
Busch,  162 
Busk,  28 
Butcher,  78 
Butlin,  39,  237 


Cadge,  170 

Callender,  72,  94,  187,  198,  270 

Callisen,  60 

Garden, 10 

Carte,  15 

Cassells,  183 

Chapman,  147 

Charcot,  178,  201,  282 

Chauveau,  280,  282 

Cheyne,  Watson,  104,  283 

Chiene,  102,  162,  284 

Chopart,  7 

Civiale,  173,  175 

Clarke,  Bruce,  95 

Clarke,  Fairlie,  237 

Clay.  196 

Cline,  87,  91,  97 

Clover,  9,  12,  32,  173,  175,  237 

Coats,  232 

Cock,  71 

Cohnheim,  145 

Colles,  72,  95 

Collins,  119 

Cooper,  Sir  Astley,  43 


318 


INDEX. 


Cooper,  T.,  102 
Coote,  Holmes,  237 
Corrigan,  28,  204 
Cowling,  218 
Coxeter,  107 
Creighton,  291 
Cripps,  19 
Crocker,  197 
Croft,  78 
Curling,  227,  229 


D'Ancona,  45 
Davy,  8,  111,  213 
Delahaye,  167 
De  Lignorolles,  8 
Delore,  162 
Desmarres,  224    - 
De  Wilde,  106 
Diday,  225,  290 
Dieulafoy,  188 
Dolbeau,  173 
Donovan,  74 
Doran,  285 
Dreschfeld,  143 
Druitt,  49 
Duchenne,  178,  179 
Dunn,  269 
Dupuytren,  65,  215 
Duret,  73,  240 
Durham,  239 


Eade,  33 

Eidam,  281 

Erb,  179,  183 

Erichsen,  35,  92,  124,  189,  190,  237 

Esmarch   (including  "the  bandage"),  6, 

16,  37,  38,  54,  78,  80,  151,  277 
Evans,  84 


Fatjvel,  167 
Ferguson,  187 
Ferrier,  73,  240 
Fitzgibbon,  234 
Flower,  71 
Foster,  Michael,  264 
Friinkel,  288 
Frazer,  234 
Fritz,  240 
Fuller,  239 


Gamgee,  120,  185,  376,  377 

Garrod,  234 

Garson,  133 

Gee,  389 

Gmelin,  264 

Golz,  208 

Goodhart,  133,  311 

Gordon,  89,  95 

Gritti,  10,  171 

Gross,  29 

Guthrie,  25 


Hainsby,  116 

Halford,  28 

Hall,  Marshall,  25 

Hamilton,  79 

Hancock,  8 

Hart,  16 

Hasse,  139 

Hawkins,  Caesar,  61 

Henle,  182 

Hennig,  288 

Hey,  7,  35,  37 

Hill,  Berkeley,  235 

Hilton,  3 

Hitzig,  240 

Holmes,  14,  17,  39,  34,  56,  63,  66,  105, 

116,  177,  315,  367 
Hood,  218 
Howard,  25 
Howse,  269,  288 

Humphry,  98,  191,  206,  238,  339 
Hunter,  15,  219,  220 
Hutchinson,  J.,  147,  319,  235,  367,  389, 

290 
Hyde,  13 

ILOTT,  193 

Jackson,  Hughlikgs,  389 
Jordan,  Fumeaux,  39,  150,  190 

Keber,  289 

Klebs,  279,  280,  383,  291 

Klein,  291 

Koch,  280-283 

Lallemand,  141,  310 
Lancereaux,  321,  223 


INDEX 


319 


Langenbeck,  151,  185 

Langton,  130 

Lawson,  239,  240 

Leach,  H.,  206 

Lecompte,  106 

Lee,  269,  270 

Lees,  179 

Legg,  109 

Lewis,  136 

Lisfranc,  8 

Lister,  6,  7,  8,  9,  18,  80,  88,  98,  111, 

277 
Listen,  87,  90,  91 
Littre,  60 

Longmore,  106,  107 
Louis,  73 
Lowne,  215 
Lucas,  Clement,  203 
Lyons,  93,  236,  290 


Macewen,  163,  166,  284,  285 

Mclntyre,  87,  97 

Malgaigne,  64,  94 

Marsh,  H.,  153,  207,  388 

Marshall,  40 

Martin,  158,  239 

Mikulicz,  162 

Mills,  152,  237 

Milton,  44,  102 

Montgomery,  143 

Morgan,  268 

Morton,  215 

MouUin,  208 

Murray,  17 

Nares,  Sir  George,  206 

Neale,  189 

Nelaton,  8,  68,  95,  106 

Niemeyer,  49,  139,  165,  178,  182,  209 

Nunneley,  336 


OasTON,  60,  163,  280,  284 
Orth,  279 
Osborne,  137 
Otis,  170 
Owen,  288 


376, 


Packard,  80 
Pagan,  329 


Page  (Carlisle),  227 

Paget,  Sir  J.,  3,  31,  37,  38,  55,  84,  98,  139, 

141,  159,  160,   175,  197,  198,  204,  205, 

208,  218,  225,  336,  270,  371 
Partridge,  191 
Pasteur,  276,  280,  383 
Pavy,  264 
Peitavy,  75 
Petit,  111 
Pilcher,  95,  218 
Pirogoff,  6,  8 
Pirrie,  4 
Poland,  233 
Pollock,  148,  187 
Porter,  109 
Pott,  39,  40,  65,  91,  122,  137,  203,  208, 

311 


Reeves,  163 
Regnoli,  236 
Reid,  W.,  15 
Rendle,  12 
Reynolds,  178 
Richardson,  232,  236,  271 
Ricord,  221 
Rindfleisch,  32,  280 
Ringer,  164 
Rivington,  17 
Rizzoli,  151 
Robbins,  13 
Roosa,  183 


Salter,  80,  87,  158 

Sansom,  55 

Savory,  139,  205,  208,  314,  238 

Sayre,   18,  26,  78,  135,  158,  190,  203,  309, 

213,  314,  316 
Sequard,  Brown-,  333 
Scarpa,  59 
Schoenlein,  279 
Schrotter,  166 
Schuller,  291 
Scott,  156,  158 
Sedillot,  336 
Sibley,  53 
Sigmund,  325 
Signorini,  111 
Simon,  143 
Simpson,  Sir  J.,  4 
Sims,  Marion,  57 


320 


INDEX. 


Sinkler,  178 

Skey,  71 

Smith,  Alder,  133 

Smith,  H.,  114 

Smith,  N.  R.,  173 

Smith,  T.,  7,  33,  116,  180,  187, 193,  237 

Smyth,  24 

Spence,  6,  10,  94 

Square,  160 

Stanley,  39,  82 

Startin,  187 

StatoD,  101 

Sylvester,  25 

Syme,  3,  7, 17,  229 


Tayloe,  289 

Teale,  5,  6,  10 

Teale,  T.  P.,  159 

Teevan,  29,  172,  195 

Thomas,  W. ,  75 

Thomas  (Liverpool),  135 

Thompson,   Sir  H.,  26,  28,  49,  102,  170, 

191,  194,  195,  196 
Thompson,  Hugh,  290 
Tiemann,  107 
Toussaint,  282 
Trendelenburg,  152,  166,  239 


Trommer,  264 
Trousseau,  138,  178 
TufneU,  16 


Vanzetti,  57 
Vermale,  10 
Vemeuil,  101 


Wagstafpe,  44 
Wakley,  258 

Walker  (Peterborough),  213 
Walsham,  34,  39,  52 
Wardrop,  17 
Watson,  P.  a,  15,  80 
Weeks,  25,  26 
Wcgner,  289 
Wheelhouse,  29,  263 
White,  P.  P.,  29 
Whitehead,  237 
Wilders,  102 
Willett,  17,  84,  210,  213 
Williams,  C.  J.  B.,  205 
Wolfe  (Glasgow),  209 
Wood,  John,  29,  126,  190 
Wormald,  237,  268 


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